AH2 Test 2 Mod 7-11

A nurse is caring for a client who asks why the provider bases the medication regimen on HbA1c results instead of the log of mornings fasting blood glucose results. Which of the following responses should the nurse make? ATI MS 516 A) "HbA1c measures how well insulin is regulating your blood glucose between meals." B) "HbA1c indicates how well you have regulated your blood glucose over the past 120 days." C) "HbA1c is the first test your doctor prescribed to determine that you have diabetes." D) "HbA1c determines if your doctor should adjust your insulin dosage."

B) "HbA1c indicates how well you have regulated your blood glucose over the past 120 days."

After teaching a patient who has alcohol-induced cirrhosis, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching? A) "I cannot drink any alcohol at all anymore." B) "I need to avoid protein in my diet." C) "I should not take over-the-counter medications." D) "I should eat small, frequent, balanced meals."

B) "I need to avoid protein in my diet."

A nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting repaglinide. Which of the following statements by the client indicates understanding of the administration of this medication? ATI Pharm 316 A) "I'll take this medication after I eat." B) "I'll take this medicine 30 minutes before I eat." C) "I'll take this medication just before I go to bed." D) "I'll take this medication at least 1 hour before I eat."

B) "I'll take this medicine 30 minutes before I eat."

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? ATI MS 371 A) Presence of immunoglobulin G antibodies (IgG) B) Positive EIA test C) Aspartate aminotransferase (AST) 35 units/L D) Alanine aminotransferase (ALT) 15 IU/L

B) Positive EIA test

A nurse is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse expect? SATA ATI MS 543 A) IV therapy with 0.45% sodium chloride B) Regular insulin C) Hydrocortisone sodium succinate D) Sodium polystyrene sulfonate E) Furosemide

B) Regular insulin C) Hydrocortisone sodium succinate D) Sodium polystyrene sulfonate E) Furosemide

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? A) The blood urea nitrogen (BUN) level is 67 mg/dL. B) Urine output over an 8-hour period is 200 mL. C) The serum potassium is 4.9 mEq/L. D) The creatinine level is 3.0 mg/dL.

B) Urine output over an 8-hour period is 200 mL.

A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? ATI MS 557 A) Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B) Administer a slow IV infusion of 3% sodium chloride. C) Rapidly administer an IV infusion of 0.9% sodium chloride. D) Add glucose to the IV infusion when blood glucose is 350 mg/dL.

C) Rapidly administer an IV infusion of 0.9% sodium chloride.

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? SATA ATI MS 396 A) Reduced BUN B) Elevated cardiac enzymes C) Reduced urine output D) Elevated blood creatinine E) Elevated blood calcium

C) Reduced urine output D) Elevated blood creatinine

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? ATI MS 524 A) "I can drink up to 2 quarts of fluid a day." B) "I will need to use insulin to control my blood glucose levels." C) "I should expect to gain weight during this illness." D) "I might experience confusion or balance problems."

D) "I might experience confusion or balance problems."

A nurse is caring for a client with alcohol dependence who was admitted for abdominal pain. The client begins to have dark brown "coffee-like" emesis. What is the priority intervention? A) Assess vital signs. B) Call the health care provider. C) Place an 18-gauge peripheral IV. D) Assist the client to turn to one side.

D) Assist the client to turn to one side.

A nurse is caring for a client who is taking somatropin to stimulate growth. The nurse should plan to monitor the client's urine for which of the following? ATI Pharm 327 A) Bilirubin B) Protein C) Potassium D) Calcium

D) Calcium

A nurse is caring for a client with DKA. What finding does the nurse expect to see on the ABG? A) Increase pH. B) Decreased pO2 C) Increase pCO2. D) Decreased HCO3.

D) Decreased HCO3.

Which clinical findings indicate a complication from diabetes insipidus? A) Urine specific gravity - 1.001 B) Serum sodium - 135mEq/L C) Urine output > than 200 ml/hr. D) Weight loss of 2 lbs.

D) Weight loss of 2 lbs.

What factor increases an older adult's risk for a distributive (septic) shock? a. Reduced skin integrity. b. Diuretic therapy. c. Cardiomyopathy. d. Musculoskeletal weakness.

A)

Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A.) Passage of two or three soft stools daily B.) Evidence of watery diarrhea C.) Daily deterioration of clients hand-writing D.) Appearance of frothy, foul-smelling stools

A)

The nurse is caring for a patient with an arteriovenous fistula. What is important to include in the nursing care for this patient? Select all that apply. A. Assess the patient's distal pulses and circulation in the arm with the access B. Encourage routine range-of-motion exercises on both arms C. Avoid venipuncture or IV administration on the arm with the access D. Instruct the patient to carry heavy objects to build muscular strength E. Assess for manifestations of infection of the fistula

A) B) C) E)

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.) A. "You have flexible scheduling for the exchanges." B. "You will have no risk for infection with PD." C. "You will not need vascular access to perform PD." D. "PD takes less time than hemodialysis treatments." E. "There is less restriction of protein and fluids."

A) C)

A nurse is caring for a client who has disseminated intravascular congestion (DIC).Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply). a. Platelets of 100 000. b. Fibrinogen levels 57 mg/dL. c. Fibrin degradation products 4.3 mcg/mL d. D-dimer 0.03 mcg/mL. e. Sedimentation rate 38 mm/hr.

A) C)

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to18 breaths/min and the pulse rate increased from86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best? a. Assess using the MEWS score. b. Document the findings in the client's chart. c. Ask if the client needs pain medication. d. Increase the rate of the client's IV infusion.

A)

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure(MAP)? a. Lower blood volume lowers MAP. b. There is no direct correlation to MAP. c. It raises cardiac output and MAP. d. It causes vasoconstriction and increased MAP.

A)

A patient has returned to the medical-surgical unit after having dialysis treatment. The nurse notes that the patient is also scheduled for an invasive procedure on the same day. What is the primary rationale for delaying the procedure for 4 to 6 hours? A. The patient was heparinized during dialysis B. The patient will have cardiac dysrhythmias C. The patient will be incoherent and unable to give consent D. The patient needs routine medications that were delayed

A)

The nurse is caring for a client at risk for septic shock from a wound infection. To prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? a. Client's pulse rate and quality. b. Client's electrolyte balance. c. Localized infected area. d Client's intake and output.

A)

The nurse is caring for a client with sepsis. What is a late clinical manifestation of shock? a. Decrease in blood pressure >20mmHg b. MAP is decreased by less than 10 mmHg. c. Tachycardia with a bounding pulse. d. Increased urine output.

A)

Your client is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A) Assessing the client's neurologic status every 2 hours B.) Monitoring the client's hemoglobin and hematocrit levels C.) Evaluating the client's serum ammonia level D) Monitoring the client's handwriting daily E.) Preparing to insert an esophageal tamponade tube F.) Making sure the client's fingernails are short

A) C) D)

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? SATA ATI MS 478 A) "I will clean the pins more often if drainage from the pins increases." B) "I will use a separate cotton swab for each pin." C) "I will report loosening of the pins to my doctor." D) "I will move my leg by lifting the device in the middle." E) "I will report increased redness at the pin sites."

A) "I will clean the pins more often if drainage from the pins increases." B) "I will use a separate cotton swab for each pin." C) "I will report loosening of the pins to my doctor." E) "I will report increased redness at the pin sites."

What is the priority of care for a client who is experiencing septic shock from urosepsis? A) Administer antibiotic therapy as prescribed B) Administer diphenhydramine (Benadryl) as prescribed C) Monitor mean arterial pressure (MAP) D) Assess for a bounding pulse

A) Administer antibiotic therapy as prescribed

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? ATI MS 478 A) Altered mental status B) Reduced bowel sounds C) Swelling of the toes distal to the injury D) Pain with passive movement of the foot distal to the injury

A) Altered mental status

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? ATI MS 478 A) Antibiotic therapy should continue for 3 months B) Relief of pain indicates the infection is eradicated C) Airborne precautions are used during wound care D) Expect paresthesia distal to the wound

A) Antibiotic therapy should continue for 3 months

A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? ATI MS 244 A) Cardiogenic B) Obstructive C) Hypovolemic D) Distributive

A) Cardiogenic

The nurse is caring for a client at risk for septic shock from a wound infection. To prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? A) Client's pulse rate and quality B) Client's electrolyte balance C) Localized infected area D) Client's intake and output

A) Client's pulse rate and quality

The nurse is caring for a client with sepsis. What is a late clinical manifestation of shock? A) Decrease in blood pressure B) MAP is decreased by less than 10 mmHg C) Tachycardia with a bounding pulse D) Increased urine output

A) Decrease in blood pressure

The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding is the priority? A) Deviated trachea to one side B) Unequal pupils C) Ecchymosis in the flank area D) Irregular apical pulse

A) Deviated trachea to one side

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? SATA ATI MS 462 A) Encourage clients who smoke to consider smoking cessation programs. B) Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range C) Instruct clients to unplug electrical equipment when performing repairs D) Encourage clients who have vascular disease to maintain good foot care E) Advise clients to wait 2 hr after taking pain medication before driving

A) Encourage clients who smoke to consider smoking cessation programs. B) Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range C) Instruct clients to unplug electrical equipment when performing repairs D) Encourage clients who have vascular disease to maintain good foot care

A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? SATA ATI MS 462 A) Encourage dependent positioning of the residual limb B) Inspect for presence and amount of drainage C) Implement shrinkage intervention of the residual limb D) Wrap the residual limb in a circular manner using gauze E) Assess for feelings of body image changes

A) Encourage dependent positioning of the residual limb B) Inspect for presence and amount of drainage C) Implement shrinkage intervention of the residual limb E) Assess for feelings of body image changes

Which of the following best describes the focus of secondary injury prevention? A) Enhancement of outcomes related to the traumatic injury B) Reduction in the severity of the injury that has occurred C) Prevention of the occurrence of the injury D) Improvement of outcomes related to non-traumatic injuries

A) Enhancement of outcomes related to the traumatic injury

The nurse is assessing a client who is in the emergency department with a concussion after falling down the stairs at home. What assessment findings require immediate follow-up by the nurse? Select all that apply: A) Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour B) The client has a headache 2/10 on the pain scale C) The client has nystagmus when gazing to the left side of the room D) The client cannot remember falling down the stairs E) The client is sleepy but easily aroused

A) Glasgow Coma Scale (GCS) score goes from 15 to 13 over an hour C) The client has nystagmus when gazing to the left side of the room

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? ATI MS 12 A) Head-tilt, chin-lift B) Modified jaw thrust C) Hyperextension of the head D) Flexion of the head

A) Head-tilt, chin-lift

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? ATI MS 273 A) Heparin B) Vitamin K C) Mefoxin D) Simvastatin

A) Heparin

The nurse is caring for a client who has had significant blood loss during a motor vehicle accident resulting in abdominal trauma. When implementing the plan of care, which interventions are most important to decrease risk of hypovolemic shock? Select all that apply: A) Initiate fluid resuscitation B) Monitor urine output C) Weight the client regularly D) Administer pain medications intravenously E) Assess for blood in urine and stool F) Control bleeding from external injuries

A) Initiate fluid resuscitation F) Control bleeding from external injuries

A nurse is assessing a client who has an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? SATA ATI MS 478 A) Intense pain when the client's left foot is passively moved B) Capillary refill of 3 sec on the client's left toes C) Hard, swollen muscle in the client's left leg D) Burning and tingling of the client's left foot E) Client report of minimal pain relief following a second dose of opioid medication

A) Intense pain when the client's left foot is passively moved C) Hard, swollen muscle in the client's left leg D) Burning and tingling of the client's left foot E) Client report of minimal pain relief following a second dose of opioid medication

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SATA ATI MS 506 A) Limit visitors in the client's room B) Encourage fresh vegetables in the diet C) Increase protein intake D) Instruct the client to consume 2,000 calories/day E) Restrict fresh flowers in the room

A) Limit visitors in the client's room C) Increase protein intake E) Restrict fresh flowers in the room

The nurse is planning care for a client with systemic lupus erythematosus and chronic disseminated intravascular coagulation (DIC). Which assessment findings require immediate follow up? Select all that apply: A) Petechiae on lower arms B) Oozing from intravenous sites C) Decreased heart rate D) Increased urinary output E) Altered mental status F) Abdominal distention

A) Petechiae on lower arms B) Oozing from intravenous sites E) Altered mental status F) Abdominal distention

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? SATA ATI MS 273 A) Platelets 100,000/mm3 B) Fibrinogen levels 120 mg/dL C) Fibrin degradation products 4.3 mcg/mL D) D-dimer 0.03 mcg/mL E) Sedimentation rate 38 mm/hr

A) Platelets 100,000/mm3 B) Fibrinogen levels 120 mg/dL

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? SATA ATI MS 12 A) Remove wet clothing B) Maintain normal room temperature C) Apply warm blankets D) Use a rapid rewarming water of 40C to 42C (104F to 108F). E) Infuse warmed IV fluids

A) Remove wet clothing C) Apply warm blankets D) Use a rapid rewarming water of 40C to 42C (104F to 108F). E) Infuse warmed IV fluids

A nurse is assessing a client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity? SATA ATI MS 462 A) Skin cool to touch from mid-calf to the toes B) Increased sensitivity to fine touch C) Palpable pounding pedal pulse D) Lack of hair on lower leg E) Blackened areas on several toes

A) Skin cool to touch from mid-calf to the toes D) Lack of hair on lower leg E) Blackened areas on several toes

A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? ATI MS 506 A) Superficial thickness B) Superficial partial thickness C) Deep partial thickness D) Full thickness

A) Superficial thickness

A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hr ago. Which of the following are findings common during this phase? SATA ATI MS 506 A) Temperature 36.1C (97F) B) Bradycardia C) Hyperkalemia D) Hyponatremia E) Decreased hematocrit

A) Temperature 36.1C (97F) C) Hyperkalemia D) Hyponatremia

The triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A.) Administer oxygen therapy via nasal cannula B.) Notify the physician C.) Obtain a complete medical history D.) Put the client on ECG monitoring

A.) Administer oxygen therapy via nasal cannula

Ten hours after the client with 50% burns is admitted, her blood glucose level is 142mg/dL. What is the nurse's best action? A.) Document the finding B.) Obtain a family history of diabetes C.) Repeat the glucose measurement D.) Stop the IV fluids containing dextrose

A.) Document the finding

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A.) Drainage of clear fluid from the client's nose B.) The client withdraws in response to painful stimuli C.) Bruises and minimal edema to the eyelids D.) Bleeding around the lacerations

A.) Drainage of clear fluid from the client's nose

How will the nurse position a client with a burn wound to the posterior neck to prevent contractures? A.) Have the client turn the head from side to side B.) Keep the client in a supine position without the use of pillows C.) Keep the client in semi-Fowlers position with his or her arms elevated D.) Place a towel roll under the client's neck or shoulder

A.) Have the client turn the head from side to side

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A.) Start Intravenous fluids B.) Check pulses using a doppler device C.) Obtain a complete blood count (CBC) D.) Obtain an electrocardiogram (ECG)

A.) Start Intravenous fluids

A nurse is assessing a client who has a severe infection and has been receiving cefotaxime for the past week. Which of the following findings indicates a potentially serious adverse reaction to this medication that the nurse should report to the provider? ATI Pharm 365 A) Diaphoresis B) Epistaxis C) Diarrhea D) Alopecia

C) Diarrhea

When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family? A.) Keeping the client in complete isolation B.) Using good sanitation with dishes and shared bathrooms C.) Avoiding contact with blood-soiled clothing or dressing D.) Forbidding the sharing of needles or syringes

B)

Which of the 4 clients do you see first? A.) Client with increasing abdominal girth B.) Client who vomited 200cc of blood C.) Client with a blood pressure of 188/110mm Hg D.) Client with biliary obstruction and temp of 100.8F

B)

A 25-year old patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? A. Blood urea nitrogen (BUN) of 56 mg/dl B. Serum potassium level of 6.5 mEq/L C. White blood cell count of 11,500/ul D. Serum creatinine level of 2.1 mg/dl

B)

A nurse is planning care for a client who has a septic shock. Which of the following actions is the priority for the nurse to take? a. Maintain adequate fluid volume with IV infusions. b. Administer antibiotic therapy. c. Monitor hemodynamic status. d. Administer vasopressor medication.

B)

A young trauma client is at risk for hypovolemic shock related to occult hemorrhage. What baseline indicator allows the nurse to recognize the early signs of shock? a. Urine output 150cc/hr b. Pulse rate 120 c. Fluid intake 800cc/24hrs d. Skin color red and warm.

B)

The nurse is caring for a postoperative client who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? a. Pulse pressure of 40 mmHg. b. A rapid, weak, thready pulse c. Warm, flushed skin. d. Increased urinary output

B)

The nurse is caring for four patients with chronic kidney disease (CKD). Which patient would the nurse assess first upon initial rounding? A) Patient with a blood pressure al 158/90 mmHg B) Patient with Kussmaul respirations C) Patient with skin itching from head to toe D) Patient with halitosis and stomatitis

B)

A nurse is reviewing client laboratory data. Which of the following findings is expected for a client who has stage 4 chronic kidney disease? ATI MS 396 A) BUN 15 mg/dl B) GFR 20 ml/min C) Blood creatinine 1.1 mg/dl D) Blood potassium 5.0 mEq/L

B) GFR 20

The nurse is caring for a 74-year-old client scheduled for a cardiac catheterization with contrast dye. What nursing action is appropriate? Select all that apply. A. Assess creatinine clearance using a 24-hour urine collection test. B. Assess client for diabetes, heart failure, and kidney disease C. Administer normal saline 500mL IV bolus prior to the procedure. D. Notify the provider about change in serum creatinine from 0.2 to 0.4mg/dl in 24 hours. E. Notify the provider of the glomerular filtration rate (GFR)<60

B) C) E)

A client is brought to the emergency department with a gunshot wound, What are the early signs of hypovolemic shock the nurse should monitor? (Select all that apply). a. Elevated serum potassium level. b. Increase in heart rate. c. Decrease in oxygen saturation. d. Marked decrease >20mm Hg in blood pressure. e. Increase in respiratory rate. f. Decreased MAP of 10-15 mmHg.

B) E)

A client comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? A) Whole blood B) 0.5% dextrose in water C) 0.9% sodium chloride D) Plasma protein fractions

B) 0.5% dextrose in water

Which client would be highest risk for development of a DVT? A) A middle-aged client who is postop for hernia repair B) A middle-aged client in traction for a fractured hip C) An elderly client who is post-bronchoscopy D) An elderly client who has osteoarthritis

B) A middle-aged client in traction for a fractured hip

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? ATI MS 244 A) Maintain adequate fluid volume with IV infusions B) Administer antibiotic therapy C) Monitor hemodynamic status D) Administer vasopressor medication

B) Administer antibiotic therapy

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? ATI MS 478 A) Skeletal traction B) Buck's traction C) Halo traction D) Bryant's traction

B) Buck's traction

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? ATI MS 12 A) Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL B) Client who reports right calf pain and shortness of breath C) Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D) Client who has dark red coloration of left toes and absent pedal pulse

B) Client who reports right calf pain and shortness of breath

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? SATA ATI MS 12 A) Induce vomiting B) Instill activated charcoal C) Perform a gastric lavage with aspiration D) Administer syrup of ipecac E) Infuse IV fluids

B) Instill activated charcoal C) Perform a gastric lavage with aspiration E) Infuse IV fluids

A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following actions should the nurse include? ATI MS 462 A) Limit any type of exercise to the residual limb for the first 48 hr after surgery B) Position the client prone several times each day C) Wrap the residual limb in a figure-eight pattern D) Encourage sitting in a chair during the day

B) Position the client prone several times each day

A client comes to the emergency department after sustaining burns from a house fire. The client has 27% total body surface area that is affected. What are the priority nursing actions? Select all that apply: A) Immerse the client in cool water B) Remove as much of the client's clothing as possible C) Administer opioid analgesics as prescribed D) Initiate two intravenous lines E) Flush the client's eyes with tap water F) Insert an indwelling urinary catheter

B) Remove as much of the client's clothing as possible C) Administer opioid analgesics as prescribed D) Initiate two intravenous lines F) Insert an indwelling urinary catheter

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? SATA ATI MS 244 A) Heart rate 60/min B) Seizure activity C) Respiratory rate 42/min D) Increased urine output E) Weak, thready pulse

B) Seizure activity C) Respiratory rate 42/min E) Weak, thready pulse

Which of these clinical assessment findings would indicate a therapeutic response from dopamine for a client who is in hypovolemic shock? Select all that apply: A) Peripheral pulses remain difficult to palpate B) Urine output increased from 45 mL/hour to 60 mL/hour C) Blood pressure from 140/90 to 98/64 in 2 hours D) Central venous pressure (CVP) from 2 mmHg to 6 mmHg E) Increase in state of alertness

B) Urine output increased from 45 mL/hour to 60 mL/hour D) Central venous pressure (CVP) from 2 mmHg to 6 mmHg E) Increase in state of alertness

Which assessment indicates the expected outcome of the fluid resuscitation for a client with a burn injury? A) Heart rate increased from 58 to 110 B) Urine output was 28 mL/hour and is now 60 mL/hour C) Decreased level of consciousness D) Peripheral pulses 1+ bilaterally

B) Urine output was 28 mL/hour and is now 60 mL/hour

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client? A.) Current range of motion in all extremities B.) Heart rate and rhythm C.) Respiratory rate and pulse oximetry reading D.) Orientation to time, place, and person

B.) Heart rate and rhythm

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A.) How to maintain home smoke detectors B.) Joining a community reintegration program C.) Learning to perform dressing changes D.) Options available for scar removal

C

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? ATI MS 273 A) Petechiae on the upper chest B) Hypotension C) Cyanotic nail beds D) Severe headache

C) Cyanotic nail beds

A client comes to the emergency department (ED) with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? a. Whole blood. b. 0.5% dextrose in water. c. 0.9% sodium chloride. d. Plasma protein fractions.

C)

A client has cardiac dysrhythmias and pulmonary problems as a result of receiving the first dose of a new IV antibiotic. The nurse recognizes that this represents what type of shock? a. Hypovolemic. b. Cardiogenic c. Anaphylactic d. Septic

C)

A client receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? a. Decreased urine output and decreased blood pressure. b. Increased respiratory rate and increased urine output. c. Chest pain and hypertension d. Bradycardia and headache

C)

A client who is diagnosed with acute pancreatitis is under the care of a nurse. Which intervention should the nurse include in the care plan for the client? A.) Administration of vasopressin and insertion of a balloon tamponade B.) Preparation for a paracentesis and administration of diuretics C.) Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction D.) Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day

C)

A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? a. Methylprednisolone IV bolus. b. Diphenhydramine subcutaneously. c. Epinephrine IM. d. Albuterol inhaler.

C)

Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful? A.) 4-6 small meals of low-carbohydrate foods daily B.) High-fat, high-carbohydrate meals C.) Low-fat, high-carbohydrate meals D.) High-fat, low protein meals

C)

The ICU nurse is caring for a client with septic shock. Which IV infusion order for this patient does the nurse question? a. Antibiotics. b. Insulin. c. 10% dextrose in water. d. Synthetic activated C protein.

C)

The nurse is caring for a client at risk for sepsis. Why does the nurse closely monitor the client for early signs of shock? a. The client is unable to self-identify or report these early signs. b. Distributive shock usually begins as a bacterial or fungal infection. c. Prevention of septic shock is easier to achieve in the early phase. d. The is widespread vasodilation and pooling of blood in some tissues

C)

The nurse is providing care for a client who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? A.) "Jaundice is associated with pressure ulcer formation B.) "Jaundice impairs urea production, which produces pruritus. C.) "Jaundice produces pruritus due to impaired bile acid excretion D.) "Jaundice leads to decreased tissue perfusion and subsequent breakdown."

C)

The nurse is providing discharge teaching to a client recovering from kidney transplantation. Which client statement indicates understanding? A. "I can stop my medications when kidney function returns to normal." B. "If my urine output decreases I will increase my fluids." C. "The antirejection medications will be taken for life." D. "I will drink 8 ounces (236 ml) of water with my medications."

C)

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A.) A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating. B.) An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. C.) A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. D.) A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

C) A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? ATI MS 12 A) Perform defibrillation B) Prepare for transcutaneous pacing C) Administer IV epinephrine D) Elevate the client's lower extremities

C) Administer IV epinephrine

The following clients come to the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. A.) A 57-year old woman that complains of a sore throat and gnawing mid-epigastric pain that is worse between meals and during the night. B.) A 15-year old boy with a low grade fever right lower quadrant pain, vomiting, and nausea, and loss of appetite over the past few days. C.) A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as tearing sensation within the past hour. D.) A 43-year old women with moderate right upper quadrant pain who has vomited a small amount of yellow bile and whose symptoms have worsened over the past week. E.) A 27-year old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.

C) Aortic aneurysm E) Ectopic pregnancy B) Appendicitis D) Gallbladder A) GERD

A nurse is caring for a client who has a cerebrospinal fluid infection with gram-negative bacteria. Which of the following cephalosporin antibiotics should the nurse expect to administer IV to treat this infection? ATI Pharm 365 A) Cefaclor B) Cefazolin C) Cefepime D) Cephalexin

C) Cefepime

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? ATI MS 244 A) Methyprednisolone B) Diphenhydramine C) Epinephrine D) Dobutamine

C) Epinephrine

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? ATI MS 273 A) Bradycardia B) Hypertension C) Epistaxis D) Xerostomia

C) Epistaxis

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? ATI MS 506 A) Pulmonary edema B) Bacterial pneumonia C) Inhalation injury D) Carbon monoxide poisoning

C) Inhalation injury

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication? ATI MS 506 A) Subcutaneous B) Oral C) Intravenous D) Transdermal

C) Intravenous

A 23-year-old client with a full thickness burn is being prepared for discharge from the hospital. Which patient education is most important for the nurse to provide prior to discharge? A) How to maintain home smoke detectors B) Joining a community reintegration program C) Learning to perform dressing changes D) Options available for scar removal.

C) Learning to perform dressing changes

A nurse is preparing to administer Penicillin V to a client who has streptococcal infection. The client reports difficulty swallowing tablets and doesn't "do well" with liquid or chewable medications because of the taste, even when the nurses mixes the medication with food. The nurse should request a prescription for which of the following medications? ATI Pharm 365 A) Fosfomycin B) Amoxicillin C) Nafcillin D) Cefaclor

C) Nafcillin

Which of these lab results is the highest priority to report to the HCP for the client with Addison's disease? A) Serum calcium 7mg/dL B) Serum potassium 3.1 mEg/L C) Serum glucose 50mg/dL D) Serum sodium 148 mEg/L

C) Serum glucose 50mg/dL

Which action by the LPN requires the nurse to intervene immediately while caring for a client on protective isolation for a burn injury? A) The LPN is providing the client with clean sheets and linens B) The LPN is performing strict handwashing technique C) The LPN is delivering a vase of flowers to the client D) The LPN is wearing gloves and a gown when assisting with wound dressing changes.

C) The LPN is delivering a vase of flowers to the client

Which staff nurse may need further instruction regarding wearing the appropriate personal protective equipment? A) the RN wears gown and gloves when entering the room for a client with c. Diff B) The RN wears an N95 mask for a client in airborne precaution with TB. C) The LPN wears sterile gloves when bathing an infant with a Respiratory Syncytial virus (RSV) D) The LPN removes gloves and washes hands with soap and water after care for a client with Clostridium Difficile.

C) The LPN wears sterile gloves when bathing an infant with a Respiratory Syncytial virus (RSV)

A nurse is obtaining a medication history from a client who is to receive imipenem-cilastatin IV to treat an infection. Which of the following medications the client also receives increases the risk for a medication interaction? ATI Pharm 365 A) Regular insulin B) Furosemide C) Valproic acid D) Ferrous sulfate

C) Valproic acid

The nurse is caring for a client in septic shock. Which assessment finding would indicate worsening of the client's condition? A) Increase in mean arterial pressure (MAP) B) Urinary output greater than 30 mL/hour C) Blood culture report indicates Escherichia coli D) Responding inappropriately to the nurse's questions

D) Responding inappropriately to the nurse's questions

Which of these clinical assignments is the higher priority to delegate to the licensed practical nurse(LPN)? a. An older adult who needs diabetic teaching. b. An elderly client who has terminal cancer and is being transferred home for hospice care. c. An elderly client who needs assistance to the bathroom d. An elderly client in Bucks traction who is asking for pain medicine

C. An elderly client who needs assistance to the bathroom

Which order for a client who is in cardiogenic shock is a priority for the nurse to question? A) Give morphine IV as ordered B) Monitor and document the client's level of consciousness C) Monitor urine output hourly D) Start IV of normal saline at 150 mL/hour

D) Start IV of normal saline at 150 mL/hour

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?

Collect effluent sample, send to lab for culture and sensitivity, administer broad spectrum antibiotics.

A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A.) Measuring serum potassium for hyperkalemia B.) Assessing the client for hypervolemia C.) Measuring the client's weight weekly D.) Documenting precise intake and output

D)

A 75-vear-old client is admitted to the hospital with an infected finger of several days' duration. The client is lethargic and confused and has a temperature of 101.3 (38.5C). Blood pressure of 94/50mmHg, pulse 105/min, respirations 40/min, and shallow breathing. The assessment findings indicate which type of shock? a. Hypovolemic. b. Cardiogenic c. Anaphylactic. d. Septic

D)

A client with jaundice is experiencing pruritis. Which nursing intervention would be included in the care plan for the client? A.) Administering vitamin K subcutaneously B.) Applying pressure when giving I.M. injections C.) Decreasing the client's dietary protein intake D.) Keeping the client's fingernails short and smooth

D)

The IC nurse observes petechiae, ecchymosis, and blood oozing from gums and other mucous membranes of a client with septic shock. How does the nurse interpret this finding? a. Pulmonary emboli (PE). b. Acute respiratory distress syndrome (ARDS). c. Systemic inflammatory response syndrome (SIRS). d. Disseminated intravascular congestion (DIC).

D)

The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with urine output of 40 mL/hr. for the last 2 hours b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with a blood pressure change of 128/74 to 110/88mm Hg

D)

The nurse is caring for a client at risk for hypovolemic shock. What is the first sign of hypovolemic shock the nurse should monitor? a. Elevated body temperature b. Decreasing urine output c. Vasodilation d. Increasing heart rate

D)

The nurse is performing a morning shift assessment on several clients. For which client is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? a. Client with diabetes mellitus. b. Anemic client c. Client with peripheral vascular disease. d. Client with severe dehydration.

D)

Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit? A.) Jaundice, dark urine, and steatorrhea B.) Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration C.) Ecchymosis, petechiae, and coffee-ground emesis D.) Nausea, vomiting, and anorexia

D)

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? A. "I will increase my intake of fruits and vegetables to 5 per day." B. "I need erythropoietin injections to boost my immunity and prevent infections." C. "I need to get most of my protein from low-fat dairy products." D. "I will measure my output each day to help calculate the amount I can drink."

D)

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? ATI MS 244 A) A client who is having occasional PVCs on the ECG monitor B) A client who has been experiencing vomiting and diarrhea for several days C) A client who has a gram-negative bacterial infection D) A client who has a pulmonary arterial stenosis

D) A client who has a pulmonary arterial stenosis

Which client is the priority to assess immediately after hand-off/shift report? A) A client admitted with an abnormal skin lesion that has grown in size over the last month B) A client who was in a house fire 2 hours ago and is now resting quietly C) A client who is scheduled for a dressing change for a pressure ulcer D) A client with full thickness burns to the chest who is complaining of shortness of breath and chest pain

D) A client with full thickness burns to the chest who is complaining of shortness of breath and chest pain

A nurse is caring for a client who had an above-the-knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? ATI MS 462 A) Remove the initial pressure dressing. B) Encourage use of cold therapy. C) Question whether the pain is real. D) Administer an antiepileptic medication.

D) Administer an antiepileptic medication.

The nurse is performing a morning shift assessment on several clients. For which client is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? A) Client with diabetes mellitus B) Anemic client C) Client with peripheral vascular disease D) Client with severe dehydration

D) Client with severe dehydration

Which of these clinical findings indicate the priority outcome for the treatment of syndrome of inappropriate antidiuretic hormone (SIADH)? A) Specific gravity 1.029 B) Serum sodium 149 mg/dL C) Serum osmolality 310 mOsm/kg of water D) Hemoglobin 13 g/dL, Hematocrit 39%.D

D) Hemoglobin 13 g/dL, Hematocrit 39%.D

A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching? ATI MS 273 A) Warfarin therapy for atrial fibrillation B) Placental abruption C) Systemic lupus erythematosus D) Heparin therapy for deep-vein thrombosis

D) Heparin therapy for deep-vein thrombosis

The client has a long leg cast on the right leg. Assessment reveals that the right foot is pale and cool to touch, and the right leg pain is still severe with no relief from the pain medication administered 45 minutes ago. What is the priority action? A) Apply a heating pad to the right toes B) Repeat the dose of pain medication C) Remove the cast immediately D) Notify the provider immediately

D) Notify the provider immediately

A nurse is caring for an older adult client who has hypothyroidism and a new prescription for levothyroxine. Which of the following dosage schedules should the nurse expect for this client? ATI Pharm 327 A) The client will start at a high dosage, and the amount will be tapered as needed. B) The client will remain on the initial dosage during the course of treatment. C) The client's dosage will be adjusted daily based on blood levels. D) The client will start on a low dosage, which can be gradually increased.

D) The client will start on a low dosage, which can be gradually increased.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A.) Unequal pupils B.) Irregular pulse C.) Ecchymosis in the flank area D.) Deviated trachea

D. Deviated trachea

A 40-year-old male client who was burned was admitted under your care. Assessment reveal she has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first? A.) Administer Digoxin B.) Perform chest physiotherapy C.) Monitor urine output D.) Place the client in an upright position

D.) Place the client in an upright position

On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? A.) Document the findings B.) Loosening any dressings on the chest C.) Raising the head of the bed D.) Prepare for intubation

D.) Prepare for intubation

A patient has a septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased blood glucose d. Decreased blood glucose e. Increased serum lactate

a. Decreased cardiac output c. Increased blood glucose e. Increased serum lactate

The nurse is caring for multiple clients in the emergency department. Which of the following client is at greatest risk for a distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer

a. Severe head injury from a motor vehicle accident

A client is diagnosed with Disseminated Intravascular Clotting (DIC). Which of the following orders should the nurse implement first for this client? a. Administer oral anticoagulants b. Monitor cardiac enzymes every 8 hours c. Administer fresh frozen plasma and platelets d. Calculate the intake and output.

c. Administer fresh frozen plasma and platelets

The nurse is caring for a client with a blood glucose of 748 mg/ml and urinary output of 320 ml in the first hour. The vital signs are BP 72/62; pulse 128, irregular and thready; respirations 38;and temperature 97°F. The client is disoriented and lethargic with cold, clammy skin, and cyanosis in the hands and feet. What is the priority nursing action? a. Hang one unit of packed red blood cells (RBCs) b. Continue to assess vital signs c. Decrease the amount of oxygen therapy the client is receiving d. Administer intravenous normal saline

d. Administer intravenous normal saline

An older adult client with diabetes mellitus has an order for an intravenous pyelogram(IVP). What is the priority care for this client? a. Assess for allergies to dyes. b. Educate the client regarding the procedure. c. Obtain consent from the client. d. Verify prescription for the procedure with HCP.

d. Verify prescription for the procedure with HCP.

A nurse is providing teaching for a client who has a new prescription for metformin. Which of the following findings should the nurse instruct the client to report as an adverse effect of metformin? ATI Pharm 316 A) Somnolence B) Constipation C) Fluid retention D) Weight gain

A) Somnolence

A nurse is reinforcing dietary teaching to a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include? SATA ATI Nutr 91 A) "Carbohydrates should compromise 55% of daily caloric intake." B) "Use hydrogenated oils for cooking." C) "You can add table sugar to cereals." D) "Eat something if you choose to drink alcohol." E) "Use the same portion sizes to exchange carbohydrates."

A) "Carbohydrates should compromise 55% of daily caloric intake." C) "You can add table sugar to cereals." D) "Eat something if you choose to drink alcohol." E) "Use the same portion sizes to exchange carbohydrates."

A nurse cares for a patient who is prescribed lactulose. The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? A) "Diarrhea is expected; that's how your body gets rid of ammonia." B) "You may take an antidiarrheal agent daily for loose stools." C) "Do not take any more of the medication until your stools firm up." D) "We will need to send a stool specimen to the laboratory."

A) "Diarrhea is expected; that's how your body gets rid of ammonia."

A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include? SATA ATI MS 388 A) "Expect an immediate removal of the donor kidney for a hyperacute rejection." B) "You might need to begin dialysis to monitor your kidney function for a hyperacute rejection." C) "A fever is a manifestation of an acute rejection." D) "Fluid retention is a manifestation of an acute rejection." E) "Your provider will increase your immunosuppressive medications for a chronic rejection."

A) "Expect an immediate removal of the donor kidney for a hyperacute rejection." C) "A fever is a manifestation of an acute rejection." D) "Fluid retention is a manifestation of an acute rejection."

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? SATA ATI MS 362 A) "I plan to eat small, frequent meals." B) "I will eat easy-to-digest foods with limited spice." C) "I will use skim milk when cooking." D) "I plan to drink regular cola." E) "I will limit alcohol intake to two drinks per day."

A) "I plan to eat small, frequent meals." B) "I will eat easy-to-digest foods with limited spice." C) "I will use skim milk when cooking."

Which statement made by the client indicates a correct understanding of steroid therapy for Addison's disease? A) "I'll take the medicine in the morning because if I take it at night, it might keep me awake." B) "I'll take the same amount from now on". C) "I'll increase my potassium by eating more bananas". D) "This medicine probably won't affect my blood pressure".

A) "I'll take the medicine in the morning because if I take it at night, it might keep me awake."

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? A) "Tell me more about what you are thinking regarding dialysis." B) "You are the only one who can make the decision about dialysis." C) "Many people your age use dialysis and have a good quality of life." D) "It depends on which type of dialysis you are considering."

A) "Tell me more about what you are thinking regarding dialysis."

During change-of-shift report, the nurse learns about the following four patients. Which patient should the nurse see first? A) A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C). B) A 36-yr-old patient with post-operative surgical site pain rated 3 out of 10. C) A 58-yr-old patient who has compensated cirrhosis and reports anorexia. D) A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain.

A) A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C).

A nurse is admitting a client for a total hip arthroplasty. The client takes hydrocortisone for Addison's disease. Which of the following actions is the nurse's priority? ATI Pharm 327 A) Administering a supplemental dose of hydrocortisone B) Instructing the client about coughing and deep breathing C) Collecting additional information about the client's history of Addison's disease D) Inserting an indwelling urinary catheter

A) Administering a supplemental dose of hydrocortisone

A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery? SATA ATI MS 388 A) Age older than 70 years B) BMI of 41 C) Administering NPH insulin each morning D) Past history of lymphoma E) Blood pressure averaging 120/70 mmHg

A) Age older than 70 years B) BMI of 41 C) Administering NPH insulin each morning D) Past history of lymphoma

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? SATA ATI MS 388 A) Anuria B) Marked azotemia C) Crackles in the lungs D) Increased calcium level E) Proteinuria

A) Anuria B) Marked azotemia C) Crackles in the lungs E) Proteinuria

A nurse is planning care for a client who is receiving furosemide IV for peripheral edema. Which of the following interventions should the nurse include in the plan of care? SATA ATI Pharm 152 A) Assess for tinnitus B) Report urine output 50mL/hr C) Monitor blood potassium levels D) Elevate the head of bed slowly before ambulation E) Recommend eating a banana daily

A) Assess for tinnitus C) Monitor blood potassium levels D) Elevate the head of bed slowly before ambulation E) Recommend eating a banana daily

Which of the clinical findings would the nurse document in the chart, report to the health care provider, and include in the plan of care for the client with Addison's disease? (Select all that apply). A) Blood glucose 51. B) Temperature: 97.8 F (36.6 C). C) Spiked T waves on ECG monitor. D) Blood pressure: 98/64 E) Weight gain of over 2 lbs. over 2 days.

A) Blood glucose 51. C) Spiked T waves on ECG monitor. D) Blood pressure: 98/64

A nurse is caring for a client admitted to the hospital for acute gastritis and ascites secondary to chronic alcohol use and cirrhosis. What is most important to assess for? A) Blood in stool. B) Nausea and vomiting. C) Hourly urine output. D) Abdominal circumference.

A) Blood in stool.

A nurse is caring for a client who is taking propylthiouracil. Which of the following findings should the nurse monitor for as an adverse effect of this medication? ATI Pharm 327 A) Bradycardia B) Insomnia C) Heat intolerance D) Weight loss

A) Bradycardia

A nurse is planning postprocedural care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? SATA ATI MS 382 A) Check BUN and blood creatinine B) Administer medications the nurse withheld prior to dialysis C) Observe for findings of hypovolemia D) Assess the access site for bleeding E) Evaluate blood pressure on the arm with AV access

A) Check BUN and blood creatinine B) Administer medications the nurse withheld prior to dialysis C) Observe for findings of hypovolemia D) Assess the access site for bleeding

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? SATA ATI MS 524 A) Decreased blood sodium B) Urine specific gravity 1.001 C) Blood osmolarity 230 mOsm/L D) Polyuria E) Increased thirst

A) Decreased blood sodium C) Blood osmolarity 230 mOsm/L

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? SATA ATI MS 371 A) Diuretic B) Beta-blocking agent C) Opioid analgesic D) Lactulose E) Sedative

A) Diuretic B) Beta-blocking agent D) Lactulose

A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? SATA ATI MS 557 A) Drink 2 L fluids daily. B) Monitor blood glucose every 4 hr when ill. C) Administer insulin as prescribed when ill. D) Notify the provider when blood glucose is 200 mg/dL. E) Report ketones in the urine after 24 hr of illness.

A) Drink 2 L fluids daily. B) Monitor blood glucose every 4 hr when ill. C) Administer insulin as prescribed when ill. E) Report ketones in the urine after 24 hr of illness.

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHS)? SATA ATI MS 557 A) Evidence of recent myocardial infarction B) BUN 35 mg/dL C) Takes a calcium channel blocker D) Age 77 years E) Daily insulin injections

A) Evidence of recent myocardial infarction B) BUN 35 mg/dL C) Takes a calcium channel blocker D) Age 77 years

The nurse is caring for a 66-year-old client who had a meningioma removed yesterday. The nurse monitors for complications of cranial surgery, including diabetes insipidus(DI). To determine if DI occurs, what assessment findings would the nurse anticipate? (Select all that apply) A) Increased urine output. B) Weak peripheral pulses. C) Poor skin turgor. D) Bradycardia. E) Acute confusion. F) Dry mucous membrane. G) Hypotension. H) Increased urine specific gravity. I) Dilute urine.

A) Increased urine output. B) Weak peripheral pulses. C) Poor skin turgor. E) Acute confusion. F) Dry mucous membrane. G) Hypotension. I) Dilute urine.

A nurse is planning care for a client who has Cushing's disease. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following? SATA ATI MS 539 A) Infection B) Gastric ulcer C) Renal calculi D) Bone fractures E) Dysphagia

A) Infection B) Gastric ulcer D) Bone fractures

A nurse is caring for a client with a history of Cushing's. The nurse should identify this client is at increased risk for which of the following? (Select all that apply). A) Infection. B) Gastric Ulcer. C) Nephrolithiasis D) Bone Fracture. E) Dysphagia

A) Infection. B) Gastric Ulcer. D) Bone Fracture.

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? SATA ATI MS 371 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

A) Limit physical activity B) Avoid alcohol E) Eat small frequent meals

A nurse is reviewing the health record of a client who has a syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings should the nurse expect? SATA ATI MS 516 A) Low sodium B) High potassium C) Increased urine osmolality D) High urine sodium E) Increased urine specific gravity

A) Low sodium C) Increased urine osmolality D) High urine sodium E) Increased urine specific gravity

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? SATA ATI MS 382 A) Monitor blood glucose levels. B) Report cloudy dialysate return. C) Warm the dialysate in a microwave oven. D) Assess for shortness of breath. E) Check the access site dressing for wetness. F) Maintain medical asepsis when accessing the catheter insertion site.

A) Monitor blood glucose levels. B) Report cloudy dialysate return. D) Assess for shortness of breath. E) Check the access site dressing for wetness.

A nurse is caring for a client who has primary adrenal insufficiency and is preparing to undergo an ACTH stimulation test. Which of the following findings should the nurse expect after an IV injection of cosyntropin? ATI MS 516 A) No change in plasma cortisol B) Elevated fasting blood glucose C) Decrease in sodium D) Increase in urinary output

A) No change in plasma cortisol

A nurse is planning postoperative care for a client following a kidney transplant. Which of the following actions should the nurse include? SATA ATI MS 388 A) Obtain daily weights B) Assess dressings for bloody drainage C) Replace hourly urine output with IV fluids D) Expect oliguria in the first 4 hr E) Monitor blood electrolytes

A) Obtain daily weights B) Assess dressings for bloody drainage C) Replace hourly urine output with IV fluids E) Monitor blood electrolytes

The nurse documents the vital signs of a patient with chronic cirrhosis: Heart rate = 121 beats/min Respirations = 27 breaths/min Blood pressure = 94/52 mmHg Oxygen saturation: 90% What priority interventions does the nurse anticipate? Select all that apply. A) Place an 18-gauge peripheral IV. B) Administer morphine 2mg IV push. C) Place the patient in an upright position. D) Administer normal saline 0.9% 500 mL bolus. E) Administer oxygen 2 L/min nasal cannula.

A) Place an 18-gauge peripheral IV. C) Place the patient in an upright position. D) Administer normal saline 0.9% 500 mL bolus. E) Administer oxygen 2 L/min nasal cannula.

A patient has a serum potassium level of 6.5 mEq/L, a serum creatinine level of 2 mg/dL, and urine output of 350 ml/day. What is the best action by the nurse? A) Place the patient on the cardiac monitor immediately. B) Teach the patient to limit high-potassium foods. C) Continue to monitor the patient's intake and output. D) Ask to have the laboratory redraw the blood specimen.

A) Place the patient on the cardiac monitor immediately.

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? SATA ATI MS 396 A) Provide a high-protein diet B) Assess the urine for blood C) Monitor for intermittent anuria D) Weight the client once per week E) Provide NSAIDS for pain

A) Provide a high-protein diet B) Assess the urine for blood C) Monitor for intermittent anuria

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? SATA ATI MS 382 A) Review the medications the client currently takes B) Assess the AV fistula for a bruit C) Calculate the client's hourly urine output D) Measure the client's weight E) Check blood electrolytes F) Use the access site area for venipuncture

A) Review the medications the client currently takes B) Assess the AV fistula for a bruit D) Measure the client's weight E) Check blood electrolytes

A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? SATA ATI MS 543 A) Sodium 130 mEq/L B) Potassium 6.1 mEq/L C) Calcium 11.6 mg/dL D) Blood urea nitrogen (BUN) 28 mg/dL E) Fasting blood glucose 148 mg/dL

A) Sodium 130 mEq/L B) Potassium 6.1 mEq/L C) Calcium 11.6 mg/dL D) Blood urea nitrogen (BUN) 28 mg/dL

A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for this client? SATA ATI MS 539 A) Sodium 150 mEq/L B) Potassium 3.3 mEq/L C) Calcium 8.0 mg/dL D) Lymphocyte count 35% E) Fasting glucose 145 mg/dL

A) Sodium 150 mEq/L B) Potassium 3.3 mEq/L C) Calcium 8.0 mg/dL E) Fasting glucose 145 mg/dL

Which information will be included when the nurse is teaching self-management to a chronic kidney disease (CKD) patient who is receiving peritoneal dialysis? Select all that apply. A) Take phosphate binders with each meal. B) Choose high-protein foods for most meals. C) Have several servings of dairy products daily. D) Restrict fluid intake to 3000 mL daily. E) Avoid commercial salt substitutes.

A) Take phosphate binders with each meal. B) Choose high-protein foods for most meals. E) Avoid commercial salt substitutes.

A nurse is providing information to a client who has a new prescription for hydrochlorothiazide. Which of the following information should the nurse include? ATI Pharm 152 A) Take the medication with food B) Plan to take the medication at bedtime C) Expect increased swelling of the ankles D) Fluid intake should be limited in the morning

A) Take the medication with food

A nurse is reviewing the laboratory findings for a client who might have hyperthyroidism. The nurse should identify an elevation of which of the following substances as an indication that the client has this disorder? ATI MS 516 A) Triiodothyronine B) Plasma-free metanephrine C) Urine cortisol D) Urine osmolality

A) Triiodothyronine

A nurse is caring for a client with chronic cirrhosis. Which potential complication would cause the nurse the most concern? A) Varices. B) Fetor hepaticus. C) Asterixis. D) Ascites.

A) Varices.

A nurse is caring for a client with Addison's disease. Which of the following manifestations will the nurse expect? (Select all that apply). A) Weakness. B) Hyperpigmentation. C) Postural hypotension. D) Constipation. E) Diarrhea F) Bradycardia

A) Weakness. B) Hyperpigmentation. C) Postural hypotension.

At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? ATI MS 539 A) Weight gain B) Fatigue C) Fragile skin D) Joint pain

A) Weight gain

A nurse is preparing to administer nafcillin IM to an adult client who has an infection. Which of the following actions should the nurse plan to take? SATA ATI Pharm 365 A) Select a 25-gauge, 1/2-inch needle for the injection. B) Administer the medication deeply into the ventrogluteal muscle. C) Ask the client about an allergy to penicillin before administering the medication. D) Monitor the client for 30 min following the injection. E) Tell the client to expect a temporary rash to develop following the injection.

B) Administer the medication deeply into the ventrogluteal muscle. C) Ask the client about an allergy to penicillin before administering the medication. D) Monitor the client for 30 min following the injection.

A nurse is talking with a client who has a new diagnosis of diabetes mellitus type 2 and their caregiver. Which of the following sweeteners should the nurse include as a zero-calorie sweetener option? SATA ATI Nutr 91 A) Sucrose B) Aspartame C) Mannitol D) Xylitol E) Sucralose

B) Aspartame E) Sucralose

A nurse cares for a patient who is scheduled for a paracentesis. Which intervention would the nurse delegate to an unlicensed assistive personnel (UAP)? A) Have the patient sign the informed consent form. B) Assist the patient to void before the procedure. C) Help the patient lie flat in bed on the right side. D) Get the patient into a chair after the procedure.

B) Assist the patient to void before the procedure.

The nurse is caring for a patient with an arteriovenous (AV) fistula in the left arm. What is the most important action to include in the plan of care for AV fistula patency? A) Irrigate the fistula site with saline every 8 to 12 hours. B) Auscultate for a bruit at the fistula site. C) Assess the quality of the left radial pulse. D) Compare blood pressures in the left and right arms.

B) Auscultate for a bruit at the fistula site.

A nurse is reviewing laboratory reports of a client who has HHS. Which of the following findings should the nurse expect? ATI MS 557 A) Blood pH 7.2 B) Blood osmolarity 350 mOsm/L C) Blood potassium 3.8 mg/dL D) Blood creatinine 0.8 mg/dL

B) Blood osmolarity 350 mOsm/L

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? SATA ATI MS 371 A) Anorexia B) Change in orientation C) Asterixis D) Ascites E) Fetor hepaticus

B) Change in orientation C) Asterixis E) Fetor hepaticus

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse expect? ATI MS 524 A) Presence of glucose B) Decreased specific gravity C) Presence of ketones D) Presence of red blood cells

B) Decreased specific gravity

A nurse is assessing a client who has hypoglycemia. Which of the following findings should the nurse expect? ATI Nutr 91 A) Fruity breath odor B) Diaphoresis C) Ketones in urine D) Polyuria

B) Diaphoresis

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? SATA ATI MS 557 A) Weight gain B) Fruity odor of breath C) Abdominal pain D) Kussmaul respirations E) Metabolic acidosis

B) Fruity odor of breath C) Abdominal pain D) Kussmaul respirations E) Metabolic acidosis

A nurse is reviewing client laboratory data. Which of the following findings is expected for a client who has stage 4 chronic kidney disease? ATI MS 396 A) Blood urea nitrogen (BUN) 15 mg/dL B) Glomerular filtration rate (GFR) 20 mL/min C) Blood creatinine 1.1 mg/dL D) Blood potassium 5.0 mEq/L

B) Glomerular filtration rate (GFR) 20 mL/min

A nurse is planning care for a client who has a new prescription for torsemide. The nurse should plan to monitor for which of the following conditions as potential adverse reactions of this medication? SATA ATI Pharm 152 A) Respiratory acidosis B) Hypokalemia C) Hypotension D) Ototoxicity E) Ventricular dysrhythmias

B) Hypokalemia C) Hypotension D) Ototoxicity E) Ventricular dysrhythmias

A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? SATA ATI MS 543 A) Take the medication on an empty stomach B) Notify the provider of any illness or stress C) Report any manifestations of weakness or dizziness D) Do not discontinue the medication suddenly E) Eat a low-sodium diet

B) Notify the provider of any illness or stress C) Report any manifestations of weakness or dizziness D) Do not discontinue the medication suddenly

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? ATI MS 362 A) Instruct the client to chew the medication before swallowing. B) Offer a glass of water following medication administration. C) Administer the medication 30 min before meals. D) Sprinkle the contents on peanut butter.

B) Offer a glass of water following medication administration.

A nurse is caring for a client who has diabetes mellitus and reports feeling shaky and weak. The client's blood glucose is 53 mg/dL. Which of the following actions should the nurse take? ATI Nutr 91 A) Provide subcutaneous insulin for the client B) Offer the client 120 mL (4 oz) fruit juice C) Give the client IV potassium D) Administer IV sodium bicarbonate

B) Offer the client 120 mL (4 oz) fruit juice

A nurse is assessing a client during a water deprivation test. For which of the following complication should the nurse monitor the client? ATI MS 516 A) Bradycardia B) Orthostatic hypotension C) Neck vein distention D) Crackles in lungs

B) Orthostatic hypotension

A patient with chronic kidney disease is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood tinged sputum. What action does the nurse perform first? A) Facilitate transfer to intensive care for treatment. B) Place the patient in a high-Fowler's position. C) Continue to monitor vital signs and breath sounds. D) Administer a loop diuretic, such as furosemide.

B) Place the patient in a high-Fowler's position.

A nurse is teaching a group of clients who have diabetes about meal planning. Which of the following client statements indicates an understanding? ATI Nutr 91 A) "I will avoid having snacks." B) "I should not eat anything containing sugar." C) "I will not eat fruit canned in syrup." D) "I will not eat more than 2,800 mg of sodium a day."

C) "I will not eat fruit canned in syrup."

Which statement made by the client with Cushing's syndrome indicates a need for further teaching? A) "I realize I will have to begin an exercise program slowly and gradually". B) "I'm going to have to keep a close eye on my blood pressure". C) "I'm not really worried about getting pneumonia this winter". D) "I'll be eating food low in carbohydrates and salt".

C) "I'm not really worried about getting pneumonia this winter".

A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? ATI MS 388 A) "Decrease your intake of protein-rich foods." B) "Take this medication with grapefruit juice." C) "Monitor for and report a sore throat to your provider." D) "Expect your skin to turn yellow."

C) "Monitor for and report a sore throat to your provider."

A nurse is teaching a client who has Grave's disease and a new prescription for propranolol. Which of the following client statements indicates effective teaching? ATI Pharm 327 A) "Propranolol helps increase blood flow to my thyroid gland." B) "Propranolol is used to prevent excess glucose in my blood." C) "Propranolol will decrease my tremors and fast heart beat." D) "Propranolol promotes a decrease of thyroid hormone in my body."

C) "Propranolol will decrease my tremors and fast heart beat."

A nurse is planning to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base the instructions on which of the following? ATI MS 543 A) The ACTH stimulation test measures the response by the kidneys to ACTH. B) In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH. C) ACTH is a hormone produced by the pituitary gland. D) The client is instructed to take a dose of ACTH by mouth the evening before the test.

C) ACTH is a hormone produced by the pituitary gland.

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? ATI MS 382 A) Administer an opioid medication B) Monitor for hypertension C) Assess level of consciousness D) Increase the dialysis exchange rate

C) Assess level of consciousness

A nurse is monitoring a client who is receiving spironolactone. Which of the following findings should the nurse report to the provider? ATI Pharm 152 A) Blood sodium 144 mEq/L B) Urine output 120 mL in 4 hr C) Blood potassium 5.2 mEq/L D) Blood pressure 140/90 mmHg

C) Blood potassium 5.2 mEq/L

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician? A) Determine the ultrafiltration rate for the hemodialysis. B) Assess for causes of an increase in predialysis weight. C) Check blood pressure before starting dialysis. D) Teach the patient about fluid restrictions.

C) Check blood pressure before starting dialysis.

A nurse is caring for a client who has increased intracranial pressure and is receiving mannitol. Which of the following findings should the nurse report to the provider? ATI Pharm 152 A) Blood glucose 150 mg/dL B) Urine output 40 mL/hr C) Dyspnea D) Bilateral equal pupil size

C) Dyspnea

A nurse is providing discharge teaching for a client who had a transphenoidal hypophysectomy. Which of the following instructions should the nurse include? SATA ATI MS 539 A) Brush teeth after every meal or snack. B) Avoid bending at the knees. C) Eat a high-fiber diet. D) Notify the provider of increased swallowing. E) Notify the provider of a diminished sense of smell.

C) Eat a high-fiber diet. D) Notify the provider of increased swallowing.

A nurse is caring for a client who is 6 hr postoperative following a transphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? ATI MS 539 A) RBCs B) Ketones C) Glucose D) Streptococci

C) Glucose

A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? ATI MS 362 A) Generalized cyanosis B) Hyperactive bowel sounds C) Gray-blue discoloration of the skin around the umbilicus D) Wheezing in the lower lung fields

C) Gray-blue discoloration of the skin around the umbilicus

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A) Draw a complete blood count. B) Infuse normal saline at 50 mL/hr. C) Insert urethral catheter. D) Obtain renal ultrasound.

C) Insert urethral catheter.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? A) Acetaminophen. B) Multivitamin with iron. C) Magnesium hydroxide. D) Calcium phosphate.

C) Magnesium hydroxide.

A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60mL in the past 2 hr, and blood pressure is 92/58 mmHg. The nurse should expect which of the following interventions? ATI MS 396 A) Prepare the client for a CT scan with contrast dye B) Plan to administer nitroprusside C) Prepare to administer a fluid challenge D) Plan to position the client in Trendelenburg.

C) Prepare to administer a fluid challenge

A nurse is teaching clients about the use of insulin to treat type 1 diabetes mellitus. For which of the following types of insulin should the nurse tell the clients to expect a peak effect 1 to 5 hours after administration? ATI Pharm 316 A) Insulin glargine B) NPH insulin C) Regular insulin D) Insulin lispro

C) Regular insulin

A nurse is providing teaching to a client who has a prescription for pramlintide for type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? SATA ATI Pharm 316 A) "Take oral medications 30 min before injection." B) "Use upper arms as preferred injection sites C) "Mix pramlintide with the breakfast dose of insulin." D) "Inject pramlintide just before a meal." E) "Discard open vials after 28 days."

D) "Inject pramlintide just before a meal." E) "Discard open vials after 28 days."

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? A) Bowel sounds are present. B) Electrolyte levels are normal. C) Grey Turner sign resolves. D) Abdominal pain is decreased.

D) Abdominal pain is decreased.

A diabetic patient is admitted to the hospital with a blood glucose of 748 mg/ml and urinary output of 320 ml in the first hour. The client's vital signs are Blood pressure 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F. The patient is disoriented and lethargic with cold, clammy skin, and cyanosis in the hands and feet. What is the priority nursing action? A) Hang one unit of packed red blood cells (RBCs). B) Continue to assess vital signs. C) Decrease the amount of oxygen therapy the client is receiving. D) Administer intravenous normal saline.

D) Administer intravenous normal saline.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? ATI MS 362 A) Pain in right upper quadrant radiating to right shoulder B) Report of pain being worse when sitting upright C) Pain relieved with defecation D) Epigastric pain radiating to the left shoulder

D) Epigastric pain radiating to the left shoulder

A nurse is reviewing the medical record of a client who takes desmopressin for diabetes insipidus. Which of the following findings is an adverse effect of desmopressin? ATI Pharm 327 A) Hypovolemia B) Hypercalcemia C) Agitation D) Headache

D) Headache

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? ATI MS 382 A) Hemodialysis restores kidney function B) Hemodialysis replaces hormonal function of the renal system C) Hemodialysis allows an unrestricted diet D) Hemodialysis returns a balance to blood electrolytes

D) Hemodialysis returns a balance to blood electrolytes

Which of these clinical findings indicate the priority outcome for the treatment of syndrome of inappropriate antidiuretic hormone (SIADH)? A) Specific gravity - 1.029 B) Serum sodium - 149mg/dL C) Serum osmolality - 310 mOsm D) Hemoglobin 13g/dL, Hematocrit 39 %

D) Hemoglobin 13g/dL, Hematocrit 39 %

A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? ATI MS 362 A) Decreased blood lipase level B) Decreased blood amylase level C) Increased blood calcium level D) Increased blood glucose level

D) Increased blood glucose level

The nurse documents the vital signs of a patient with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 mmHg What complication of acute pancreatitis does the nurse suspect the patient may have? A) Pleural effusion. B) Pancreatic pseudocyst. C) Electrolyte imbalance. D) Internal bleeding.

D) Internal bleeding.

A nurse is caring for a client who has been taking acarbose for type 2 diabetes mellitus. Which of the following laboratory tests should the nurse plan to monitor? ATI Pharm 316 A) WBC B) Amylase C) Platelet count D) Liver function tests

D) Liver function tests

A nurse is planning care for a client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan of care? ATI MS 524 A) Maintain the client in a low-Fowler's position. B) Encourage deep breathing and coughing. C) Encourage the client to brush their teeth when awake and alert. D) Observe dressing drainage for the presence of glucose.

D) Observe dressing drainage for the presence of glucose.

After receiving change-of-shift report, which patient should the nurse assess first? A) Patient who is scheduled for the drain phase of a peritoneal dialysis exchange. B) Patient with stage 4 chronic kidney disease who has an elevated phosphate level. C) Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L. D) Patient who has just returned from having hemodialysis with a heart rate of 110/min.

D) Patient who has just returned from having hemodialysis with a heart rate of 110/min.

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? ATI MS 371 A) Initiate contact precautions B) Weight the client weekly C) Measure the abdominal girth at the base of the ribcage D) Provide a high-calorie, high-carbohydrate diet

D) Provide a high-calorie, high-carbohydrate diet