ATI Funds Exam Review

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D Crackles are a series of short, interrupted, high pitched sounds. Rhonchi is continuous rumbling, snoring, or rattling sounds from fluid or mucous. Stridor is continuous, shrill musical sound of constant pitch.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased HR B. Dyspnea C. Increased BP D. Weak pulse

D HR will be increased to compensate for decreased blood volume. Dyspnea is a characteristic of respiratory conditions. BP will be decreased due to decreased blood volume.

A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of action the nurse should take? 1. Don sterile gloves 2. Adjust the suction 3. Hyper-oxygenate the patient 4. Assess for secretions 5. Check the function of the suction catheter 6. Insert the catheter without suction 7. Apply suction while rotating the catheter

2, 1, 5, 3, 6, 7, 4

A nurse is assessing a clients cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her finger? A. The left second intercostal space B. The right second intercostal space C. The left fifth intercostal space D. The left fifth intercostal space at the midclavicular line

A

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate C. Hyperactive bowel sounds D. Decreased blood pressure

A Acute pain can cause tachypnea, pallor, diaphoresis, and increased BP.

A nurse is auscultating a clients lung sounds and identifies crackles in the lower left lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough B. Instruct the client to limit fluid intake to less than 2,000mL/day C. Prepare to administer antibiotics D. Place the client on bed rest in semi-fowlers position.

A Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough. It is premature to impose fluid restrictions based on a one-time finding of adventitious lung sounds. Although pulmonary infections such as pneumonia and bronchitis can cause crackles, it is premature to assume that infection is the cause of this clients crackles. It is premature to impose activity restrictions at this time based on a one-time finding of adventitious lung sounds. Semi-fowlers position can help ease breathing but it will not resolve crackles.

A nurse is assessing a client who is 2 days post-op and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following post-op complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of the alveolar collapse. Pneumonia would present with crackles due to increased secretions. A PE would present with sudden chest pain, SOB, and decreased BP. Arterial thrombus would present with decreased peripheral pulses, breath sounds are not affected.

A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute B. Assess the apical pulse with a doppler device C. Assess the pedal pulses for a full minute D. Assess the pedal pulses with a doppler device

A Dopplers are not needed unless pulse cannot be heard with a stethoscope. Pedal pulse checking is not necessary due to the fact that they can also have regular or irregular pulses

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter B. Remove the nasal cannula while the client eats C. Secure the oxygen tubing to the bed sheets near the clients head D. Apply petroleum jelly to the nares as needed to smooth mucous membranes

A Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula. A client can keep a nasal cannula on while eating, drinking, and speaking. The nurse should maintain sufficient slack and secure the oxygen tubing to the clients clothing. The nurse should apply water-soluble lubricant, not petroleum jelly, as needed to soothe the mucous membranes.

A nurse is performing tracheostomy care for a client and suctioning to remove secretions. Which of the following actions should the nurse take? A. Suction 2 or 3 times with 60 second pauses between passes B. Perform chest physiotherapy prior to suctioning C. Lubricate the suction catheter tip with sterile saline D. Hyperventilate the client on 100% oxygen prior to suctioning

A Secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxemia. Perform chest physiotherapy prior to suctioning mobilizes secretions but does not remove them. Lubricate the suction catheter tip with sterile saline and hyperventilating has no effect on removing secretions

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for insertion of the suppository? A. Sims position B. Prone position C. Lying on the right side D. Supine

A The nurse should assist the client into the sims position by lying on the left, left hip and lower extremity straight, and right hip and knee bent. This position exposes the anus and helps the client relax the external sphincter, allowing for easier insertion.

A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? A. "Crushing the medication might cause you to have a stomachache or indigestion" B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you" C. "Crushing the medication would release all of the medication at once, rather than overtime" D. "Crushing is unsafe, as it destroys the ingredients in the medication"

A The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI distress. Crushing the pill destroys that protection. Crushing the pull will destroy the enteric coating, and the client should be advised against this. The client should be told no to break, crush, or chew enteric-coated tablets. The enteric coating does not prevent the release of medication. Sustained release preparation disburse the medication over time. Many medications can safely be crushed to make them easier to swallow. The client should check with his provider for information about which medications can be safely crushed.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (SELECT ALL THAT APPLY) A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine specific gravity greater than 1.030 E. Crackles upon auscultation

A, B, E

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? (SELECT ALL THAT APPLY) A. Verify the oxygen low rate every other day B. Check the nasal cannula position in a regular basis C. Check the tops of the ears for skin breakdown D. Post "no-smoking" signs in a prominent location in the home E. Apply petroleum ointment to nares if they become dry and irritated.

B,C,D

A nurse has relieved change of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A. A client who had a blood glucose reading at 0650 of 70mg/dL after receiving 50% dextrose for a hypoglycemic episode B. A client who was admitted for chest pain and is reporting a new onset of indigestion C. A client who has pneumonia and was treated for a temperature of 102F at 0400 D. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800

B A client who has a history of chest pain and is reporting a new onset of indigestion is unstable; therefore is the highest priority. Everyone else is stable.

A nurse is assessing a clients circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? A. Brachial B. Carotid C. Femoral D. Popliteal

B Assessing the carotid bilaterally can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate. The other answers can be checked at the same time to determine equally and perfusion.

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? A. Dilated pupils B. Dysrhythmias C. Diarrhea D. Gastric ulcer

B Pressure can be exerted with the valsalva maneuver, when the client contracted the abdominal muscles and hold their breath while bearing down. When the client exhales, there is a sudden release of intraabdominal pressure against the closed airway, which can result in cardiac dysrhythmias and elevated BP. Straining may result in hemorrhoids and painful defecation. Gastric ulcers are caused by a microorganism.

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client? A. Transdermal patch B. Sublingual C. Suspended-release D. Topical ointment

B Sublingual has an onset of 1-3 minutes. A transdermal patch onset is 30-60 minutes. A suspended release onset is 20-45 minutes. A topical ointment onset is 30-60 mins.

A nurse is preparing to measure a clients level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin Fold

B The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation. Every other answer may interfere with blood circulation in the capillary bed. The oximeter probe may not be able to adequately detect hemoglobin molecules to provide an accurate oxygen saturation reading.

A nurse is caring for 4 clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another. Which of the following actions should the nurse take first? A. Notify the clients provider B. Check the clients vital signs C. Fill out an occurrence form D. Administer the medication to the correct client

B The first thing the nurse should do is Check the clients vital signs. The nurse should know that nifedipine is to lower blood pressure and should ensure that the client is not hypotensive as a result. The nurse should do the rest of the options after they know the patient is stable.

A nurse is teaching a clients partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? A. Wraps the blood pressure cuff snugly around the clients arm B. Places the clients arm above the level of the clients heart C. Checks the instrument gauge to ensure the reading starts at 0 D. Center the cuff bladder over the clients brachial artery

B The partner should place the clients arm at heart level to ensure accurate blood pressure readings. Wrapping the cuff smoothly and snugly on the clients arm ensures an accurate blood pressure reading. The clients partner should check that the instrument gauge starts at 0 to ensure an accurate blood pressure reading. The clients partner should center the cuff bladder over the clients brachial artery for an accurate blood pressure reading.

A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery dose which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the clients ability to eat, speak or drink

C A nasal cannula delivers a relatively low concentration of oxygen (24%-44%), A venturi mask delivers a specific concentration of oxygen at a constant rate of flow. A nonrebreather mask with a reservoir bag delivers a high concentration of oxygen. The use of a face mask for oxygen delivery restricts the clients ability to eat, speak or drink.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intake D. Encourage regular use of the incentive spirometer

C Increasing fluid intake to 1,500 to 2,500mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the clients ability to cough and remove the secretions. Ambulation prevents the accumulation of respiratory secretions, but not their thinning. Coughing, deep breathing and incentive spirometers promotes expectorations, not thinning of respiratory secretions.

The nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advancing a clients diet. B. Reinsert an intravenous catheter that was removed due to infiltration C. Suction the tracheostomy of a client who has copious secretions D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.

C The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to suction the tracheostomy of a client who has copious secretions to clear the airway. The nurse should ask the provider about advancing a clients diet so the client is able to increase his intake; however, the nurse should perform another action first. The nurse should reinsert an intravenous catheter to continue IV therapy; however, the nurse should perform another action first. The nurse should check the laboratory findings of a preoperative client to note any abnormalities prior to surgery; however, the nurse should perform another action first.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot

C To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclera, soles of the feet, conjunctivae, and mucous membranes. The nurse should check less pigmented areas, such as the lips and tongue, not the external ear, for cyanosis in clients who have dark skin. The nurse should check the palmer surface (the palms) of the hands when assessing for cyanosis in clients who have dark skin. The nurse should check the plantar surface (the soles) of the feet when assessing for cyanosis in clients who have dark skin.

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take? A. Give the medication B. Discard the medication C. Notify the provider D. Return the medication to the pharamacy

D

A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min B. Administer prescribed analgesic medication C. Encourage coughing and deep breathing D. Raise the head of the bed

D Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs an allows for increased expansion of the lungs. The head of the neck can be extended which promotes a patent airway. This is the first action the nurse should tale and its the least invasive. The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min. Pain management promotes increased participation by the client in coughing and deep breathing, frequent positioning changes and use of the incentive spirometer, but this is not the first action the nurse should take. Coughing and deep breathing promotes lung expansion and prveents respiratory infection, nut these actions are not effective immediately in increasing oxygen saturation.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

D The nurse should expect the client who has chronic hypoxemia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size. Restlessness is an early manifestation of inadequate oxygenation. Retractions are a manifestation of increased work with breathing or dyspnea, not for chronic respiratory insufficiency. Dependent edema is a manifestation of heart failure, not chronic respiratory insufficiency.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D The nurse should expect to find rapid, shallow respirations and dyspnea. They will display restlessness and agitation. They will manifest cyanosis.