NURS 3234 Final Exam ATI/PrepU
A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?
0.5
A client tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition?
Sensory deficit
A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing?
Sensory deficits
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
Stopping the transfusion
A nurse is giving change of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Code Status
While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information?
Continue with care; this is a normal fluid intake.
The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?
Crackles in the lower lobes
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq PaCO2 28 mm Hg pH 7.30 The nurse recognizes the client is experiencing which of the following acid base imbalances?
Metabolic Acidosis
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse tell the family members to omit?
Pickled vegtables
The client is in the intensive care unit following a stroke. The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload. What independent nursing intervention would the nurse choose to do?
Play music the client chooses.
A nurse is providing instruction to a new nurse 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?
Spironolactone
The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription?
The route is missing.
A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
Tingling of the extremities
A nurse in a medsurg unit is preparing to contact a provider about a client's condition. The client is 6 hr post op from a total hysterectomy. The nurse notes the client's postop oxygen sat is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen sat level and heart rate in which component of the SBAR report?
assessment
A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?
back massage
A nurse in an ED is caring for an infant who has a 2 day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indictor of fluid loss?
body weight
After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat?
bouillon, apple juice, and gelatin
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
discontinue the existing IV line
A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration?
edema in the palm of the hand
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is:
extremely obese.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
flush the NG feeding tube with 30 mL of water immediately following medication administration
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
generalized urticaria
A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?
higher than the primary solution container
While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:
invasion of privacy.
A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:
overload
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25 HCO3- 19 mEq/L PaCO2 30 mm Hg
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 below 7.35
Which client would be at greatest risk for injury to the skin and mucous membranes?
man 77 years of age with diabetes
A nurse is caring for a young adult female client who has a folic acid deficiency. When educating the client about this condition, the nurse would include a discussion about the client's increased risk for:
neural tube deficits in the fetus.
An assistive personal (AP) reports to the nurse that a client who is 3 days postop following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
obtain vital signs
A nurse calculates the BMI of a client during a general survey as 26. Under which category would this client fall?
overweight
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?
"Antibiotics have no effect on viruses."
A nurse is discussing neonatal care with a new mother. Which statement by the nurse best describes the value of breastfeeding?
"Breastfeeding provides the neonate with immunity against some bacteria and viruses."
A nurse is conducting an interview with a client to collect a medication history. Which question would be used to ensure safe medication administration?
"Do you have any allergies to medications?"
A nurse is teaching a client who is obsese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
"If I could lose about 50 pounds, I might stop having so many apneic episodes."
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
"Information about a client can be disclosed to family members at any time"
A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosing example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?
0.2 mg
A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?
1
A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has staph infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr?
35 mL/hr
A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness (LOC). What would be the most appropriate nursing diagnosis?
Acute Confusion
Which is the most frequent reason for revocation or suspension of a nurse's license?
Alcohol or drug use
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
Hypotension
What is the route of administration for TPN?
Intravenous
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Obtain a 12-lead ECG
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion>
Temperature
A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?
The client developed a tolerance to the medication
What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU?
Use limited light
Which modification to bathing should be implemented for a client who is incontinent?
Use special perineal skin cleaners and moisture barriers.
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
Wash the site of injury with soap and water
To which client would the nurse be most likely to administer a PRN medication?
a client who is reporting pain near the surgical site
Which client receives a drug that requires a parenteral route?
a woman who has been ordered intravenous antibiotics
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?
cardiac dysrhythmias
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?
changes in the alveolar-capillary membrane and diffusion
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
compare the number of medication errors before and after the action was implemented
A nurse is caring for an older adult client who has a UTI. Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
confusion
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
reduce edema of the brain
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
remove the catheter and insert another into a different sit
A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?
shallow respirations
A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?
sitz bath
A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription?
take the extended release tablets whole
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of completely finishing the prescribed treatment
A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?
the safety measures necessary to prevent a fire
A nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step?
to clear medication and prevent clot formation
A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?
to prevent gastric irritation
A nurse is reviewing the medical record of a client who has a UTI. which of the following findings should the nurse recognize as a risk factor?
Diabetes Mellitus
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?
"I will need to wipe my perineal area from back to front after urination."
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?
"I will use conditioner so that the lice eggs will slide off my hair."
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
"The client was found unconscious on the floor at home."
A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer?
2 mL
A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A nurse is preparing to administer ticarcillin/clavulanate 3.1 g by intermittment IV bolus over 30 min. Available is ticarcillin/clavulanate 3.1 g in 50 mL 0.9% NS. The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr?
24 mL/hr
A nurse performing a nutritional assessment determines that the BMI of a 5-foot, 11-inch (1.8 m) male client who weighs 81 kg is which of the following?
25
A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated ringers IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittment bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525 mL
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
4 hr
A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer?
5.6 mL
A nurse is admitting a client who has active TB to a room on the megsurg unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
When the client demonstrates a rash 30 minutes after taking a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?
Allergy
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
Which statement about glove use and hand hygiene is true?
Artificial fingernails should not be worn by staff involved in direct client care.
A nurse is caring for a client who has HIV. Which of the following lab values is the nurse's priority?
CD4-T cell count 180 cells/mm3
The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?
Decreased level of consciousness
A nurse in the ED is caring for a client who collapsed after playing football on a hot day. After reviewing the admission lab findings, the nurse recognizes these findings are consistent with which of the following conditions? Na 152 K 3.6 Cl 105 Glucose 102 BUN 18 Creatinine 0.7
Dehydration
A client has been prescribed a clear liquid diet. Which food or fluids should the nurse serve the client?
Gelatin desert, carbonated beverages, and apple juice
A client asks the nurse whether the generic acetaminophen is as effective as the brand name product. Which is the nurse's best response?
Generic medication performs the same as the corresponding brand-name product
A client reports postoperative pain of 9 on a scale of 10 and asks the nurse whether a shot or a pill will provide the fastest pain relief. Which is the best response from the nurse?
Intravenous medication provides the fastest pain relief until you can take pills by mouth
Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?
Invasion of privacy
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?
Providing a back rub before bed
A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next?
Question the order for the medication.
The nurse is auscultating breath sounds of an infant with respiratory syncytial virus. For which finding will the nurse immediately contact the health care provider?
Quiet chest from previous assessment of wheezing
A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?
Renal Stones
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mmHg Sat 80% Bicarbonate 26 mEq/L
Respiratory Acidosis
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?
Respiratory Acidosis
A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption?
Serum albumin 2.8 g/dL (28 g/L)
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract
A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of:
allergic reaction.
What does pulse oximetry measure?
arterial oxygen saturation
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
assess the client
A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?
avoid eating within 3 hr of bedtime
