NURS 405 B ATI questions for Final

A, B, E, F

Which of the following clients have an increased risk for developing pneumonia? (select all that apply) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A, B, C

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery of coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (select all that apply) A. The clients demand for oxygen is lowered B. Motion of the heart ceases C. Rewarming of the client takes place D. The clients metabolic rate is increased E. Blood flow to heart is stopped

A

A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation B. obtain sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccination

A, B, D

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (select all that apply) A. Headache B. Dilated Pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A

A nurse is admitting a client who has a suspected MI and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI A. Angina can be relieved with rest and nitrogen B. The pain of an MI resolves in less than 15 min C. The type of activity that causes an MI can be identified D. Angina can occur for longer than 30 min

C

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

B, C, D, E, F

A nurse is assessing a client who has pancreatitis. His ABG reveals metabolic acidosis. Which of the following is an expected finding? (select all that apply) A. Tachycardia B. Hypertension C. Bounding pulses D. hyperflexia E. Dysrhythmia F. Tachypnea

A, C, D, E

A nurse is assessing a client who has prerenal AKI. Which of the following should the nurse include in the assessment? (select all that apply) A. Blood pressure B. Cardiac enzymes C. Urine output D. Serum creatinine E. Serum electrolytes

B, C

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (select all that apply) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2 + in the affected limb

D

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

A

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? A. Condom catheter B. Intermittent urinary catheterization C. Credes method D. Indwelling urinary catheter

D

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

A, B, D

A nurse is caring for a client who has a closed-head injury with ICP readings range from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (select all that apply) A. Suction the endotracheal tube B. Hyperventilate the client C. Elevate the client's head on two pillows D. Administer a stool softener E. Keep the client well hydrated

B

A nurse is caring for a client who has a new diagnosis of hep C. Which of the following is an expected lab finding? A. Presence of immunoglobin G antibodies (IgG) B. Presence of enzyme immunoassay (EIA) C. AST 35 units D. ALT 15 IU

B, C, E

A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Which of the following is an expected assessment finding? (select all that apply) A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus

A, B, D

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative

A, B, C, E

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (select all that apply) A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of awareness

A, B, C, E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (select all that apply) A. Speak to the client at a slower rate B. Look directly at the client when speaking C. Allow extra time for the client to answer D. Complete sentences that the client cannot finish E. Give instructions one step at a time

A

A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2000 ml per day. Which of the following is an appropriate response by the nurse? A. Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink B. Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day C. This is the same as 2 quarts, or about the same as two pots of coffee D. Take sips of water or ice chips so you will not take in too much fluid

B

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the clients weight B. Assist the client into high-fowler's position C. Auscultate the lungs D. Check oxygen saturation with pulse oximeter

B

A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

C

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Gaslow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

B

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body B. Place the client's bedside table on the right side of the bed C. Orient the client to the food on her plate using the clock method D. Place the client's wheelchair on her left side

B

A nurse is caring for a client who has stage 4 CKD. Which of the following is an expected lab finding? A. BUN 54 mg/dl B. GRF 20 ml/min C. Serum creatinine 1.2 mg/dl D. Serum potassium 5.0 mEq/L

C

A nurse is caring for a client who has sustained burns to 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck and shoulders. The client's voice is hoarse, and he has a brassy cough. These findings are indicative of which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

B

A nurse is caring for a client who is 4 hr postoperative following CABG surgery. He is able to inspire 200 ml with an incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest and return in 1 hr B. Administer IV bolus analgesic, and return in 15 minutes C. Document the 200 ml as an appropriate inspired volume D. Tell the client that he must try to cough if he does not want to get pneumonia

B, E

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (select all that apply) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

C, D

A nurse is caring for a client who was admitted 24 hrs ago with a deep partial-thickness and full-thickness burns to 40% of his body. Which of the following are expected findings in this client? (select all that apply) A. Hypertension B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized B. Insert nasogastric tube C. Monitor pulse and blood pressure frequently D. Establish IV access and start fluid replacement

B

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 with an apical heart rate of 54 bpm. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the client upright in bed C. Check the client's urinary catheter for blockage D. Administer antihypertensive medication

B

A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching? A. I will consume more white rice B. I will eat more baked potatoes C. I will drink more grape juice D. I will use more powdered cocoa mixes

A

A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective? A. Metabolic acidosis can occur due to diabetic ketoacidosis B. Metabolic acidosis can occur in a client who has myasthenia gravis C. Metabolic acidosis can occur in a client who has asthma D. Metabolic acidosis can occur due to cancer

D

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8 hr C. Document tube placement in cm at the angle of jaw D. Assess breath sounds every 1 to 2 hours

B

A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV? A. It keeps the alveoli open and prevents atelectasis B. It permits spontaneous ventilation to decrease the work of breathing C. It is used with clients who have difficulty weaning from the ventilator D. It delivers a preset ventilatory rate and tidal volume to the client

A, C, E

A nurse is planning care for a client who has burn injuries. Which of the following interventions should be included in the plan of care? (select all that apply) A. Use standard precautions when performing wound care B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct client to consume 3000 calories daily E. Restrict fresh flowers in room

C, E

A nurse is planning care for a client who has stage 4 chronic kidney disease. Which of the following should the nurse include in the plan of care? (select all that apply) A. Assess for jugular vein distention B. Provide frequent mouth rinse C. Auscultate for a pleural friction rub D. Assess using the glasgow coma scale E. Monitor for dysrhythmias

B, C, D

A nurse is planning care for a client who is receiving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (select all that apply) A. Assist control B. SIMV C. CPAP D. Pressure support ventilation E. Independent lung ventilation

A

A nurse is planning care for a client who suffered a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

C

A nurse is preparing to administer fentanyl (sublimaze) to a client who was admitted 24 hr ago with deep partial-thickness and full-thickness burns over 60% of his body. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Intramuscular C. Intravenous D. Transdermal

A, D, E

A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following lab findings should the nurse anticipate? (Select all that apply) A. Low serum sodium B. High serum potassium C. Decreased Urine osmolality D. High urine sodium E. Increased urine-specific gravity

A, B, C, E

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2000 mg daily. Which of the following foods should be consumed in limited quantities? (select all that apply) A. Cheddar cheese 2 oz B. Hot dog C. Canned tuna 3 oz D. Roast chicken breast, 3 oz E. Baked ham, 3 0z

A, B, E

A nurse is teaching a client who has hep B about home care. Which of the following should the nurse include in the teaching? (select all that apply) A. Limit physical activity B. Avoid alcohol C. Take acetaminophen for comfort D. Wear a mask when in public places E. Eat small frequent meals

C

A nurse on a cardiac unit is reviewing the lab findings of a client who has a diagnosis of MI and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin

D

A nurse on a med surg unit is admitting a client who has hep B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions B. Weigh client weekly C. Measure abdominal girth 7.5 cm above the umbilicus D. Provide a high-calorie, high-carbohydrate diet

A

A nurse working in a provider's office is assessing a client who has a severe sunburn. Which of the following is the proper classification of this burn? A. Superficial B. Superficial partial-thickness C. Deep partial-thickness D. Full thickness