ATI dynamic quizzing
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure ( ICP ) . Which of the following findings indicates that the medication is having a therapeutic effect ? A. The client's serum osmolarity is 310 mOsm /L . B . The client's pupils are dilated . C. The client's heart rate is 56 / min . D. The client is restless .
A. The client's serum osmolarity is 310 mOsm/L. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP.
A nurse is assessing a client who is 1 I week postoperative following a living donor kidney transplant . Which of the following findings indicates the client is experiencing acute kidney rejection . A. Blood pressure 160/90 mmHg B. Creatinine 0.8 mg / dL . C. Sodium 137 mg / dL D. Urinary output 100 ml / hr
Correct Answer : A. Blood pressure 160/90 mmHg Due to the kidneys ' role in fluid and blood pressure regulation , a client who is experiencing rejection can have hypertension .
A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy ( ESWL ) . The nurse should identify that which of the following findings the priority ? A. Dysrhythmias B. Pink - tinged urine C. Bruising on the flank area D . Stone fragments in the urine
Correct Answer : A. Dysrhythmias The nurse should apply the ABC priority - setting framework , which emphasizes the basic core of human functioning : having an open airway being able to breathe in adequate amounts of oxygen , and circulating oxygen to the body's organs via the blood . An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern . When applying the ABC priority - setting framework , airway is always the highest priority because the airway must be clear for oxygen exchange to occur . Breathing is the second - highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur . Circulation is the third - highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them . ESWL is the application of sound , laser , or dry shock wave energies to break a kidney stone into small pieces . The shock waves are initiated during the R wave of the ECG to prevent dysrhythmias . When using the ABC approach to client care , the nurse should determine that dysrhythmias are the priority finding .
A nurse is providing teaching to a young adult client who has a history of calcium oxalate renal calculi . Which of the following instructions should the nurse include ? A. " Drink fruit punch or juice with every meal . " B. " Consume 1,000 mg of dietary calcium daily . " C. " Take 1 g of a vitamin C supplement daily . " D. " Increase your daily bran intake . "
Correct Answer : B. " Consume 1,000 mg of dietary calcium daily . " Clients who are prone to the development of calcium oxalate stones should consume the recommended daily allowance for calcium for their age . The RDA for calcium for adults ages 19 to 50 is 1,000 mg daily . Calcium should be obtained from dietary sources rather than supplements that can promote the development of renal calculi .
A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence . Which of the following statements by the client indicates an understanding of the teaching ? A . " I will ask my provider to change my contraception to an intrauterine device . " B. " I will notify my doctor before I have dental procedures . " C . " I will avoid using antiseptic mouthwash for oral care . " D. " I will wear a mask when I go out in public . "
Correct Answer : B. " I will notify my doctor before I have dental procedures . " The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis . The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection .
A nurse is caring for a client who has chronic glomerulonephritis with oliguria . For which of the following electrolyte imbalances should the nurse monitor ? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hypophosphatemia
Correct Answer : B. Hyperkalemia Oliguria resulting from chronic glomerulonephritis causes potassium retention , leading to levels above the expected reference range of 3.5 to 5 mEq / L . Other electrolyte imbalances common with this disorder affect sodium and phosphorus levels . Chronic glomerulonephritis eventually leads to end stage kidney disease
A nurse is reviewing the laboratory report of a client who has chronic kidney disease ( CKD ) . The nurse finds the following laboratory test results : potassium 6.8 mEq / L , calcium 7.4 mg / dL , hemoglobin 10.2 g / dL , and phosphate 4.8 mg / dL . Which finding is the priority for the nurse to report to the provider ? A. Hypocalcemia B. Hyperkalemia C. Anemia D. Hypoalbuminemia
Correct Answer : B. Hyperkalemia The nurse should apply the urgent versus nonurgent priority - setting framework when caring for this client . Using this framework , the nurse should consider urgent needs the priority need because they pose more of a threat to the client . The nurse may also need to use Maslow's hierarchy of needs , the ABC priority - setting framework , and / or nursing knowledge to identify which finding is the most urgent . Hyperkalemia , which can cause life - threatening cardiac dysrhythmias , is the priority for the nurse to report to the provider .
A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis . Which of the following findings should the nurse report to the provider ? A. WBC 6,000 / mm ^ 3 B. Potassium 3.0 mEq / L C. Clear , pale yellow drainage D . Report of abdominal fullness
Correct Answer : B. Potassium 3.0 mEq / L A potassium level of 3.0 mEq / L is below the expected reference range and can cause dysrhythmias . Dialysis removes fluid , waste products , and electrolytes from the blood and can cause hypokalemia .
A nurse is preparing a client who is scheduled for an intravenous pyelogram ( IVP ) . Which of the following findings should the nurse report to the provider ? A. Allergy to egg products B. Vomiting and diarrhea for the last 6 hr C. Serum potassium of 3.6 mEq / L D. Serum creatinine of 1.2 mg / dL
Correct Answer : B. Vomiting and diarrhea for the last 6 hr Vomiting and diarrhea for 6 hours deplete the client's fluid volume , which results in dehydration that can cause renal failure following a procedure that uses contrast dye . Therefore , the nurse should notify the provider .
A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis ( MS ) . The client asks the nurse about the usual cause of MS . Which of the Question following responses should the nurse make ? A. " Each client is different ; we cannot predict what will happen . " B. " I can see that you are worried , but it's too soon to predict what will happen . " C. " Acute episodes are usually followed by remissions , which can vary in duration . " D. " It's too early to think about the future ; let's focus on the present and take each day as it comes . "
Correct Answer : C. " Acute episodes are usually followed by remissions , which can vary in duration . " This client is asking an information - seeking question , so the nurse should provide the client with factual information . The nurse should inform the client MS is a chronic autoimmune disorder characterized by remissions and exacerbations , with exacerbations becoming more frequent and intense as the disease progresses .
nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching ? A. " I am unable to donate blood . " B. " I will need to get a booster shot of immune serum globulin every year . " C. " I should stop eating raw clams . " D. " I can develop this disease by getting a tattoo . "
Correct Answer : C. " I should stop Hepatitis A is transmitted via the fecal - oral route through consumption of contaminated fruits , vegetables , water , milk , or uncooked shellfish
A nurse is providing teaching to a client who is preoperative for a renal biopsy . Which of the following statements should the nurse make ? A. " You will be NPO for 8 hr following the procedure . " B. " An allergy to shellfish is a contraindication to this procedure . " C. " You will need to be on bed rest following the procedure . " D. " A creatinine clearance is needed prior to the procedure . "
Correct Answer : C. " You will need to be on bed rest following the procedure . " A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney . The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding . The nurse can elevate the head of the bed .
A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago . Which of the following findings should the nurse report to the provider immediately ? A. Headache and fatigue B . Swollen lymph nodes in the neck C. Abdominal pain in the left upper quadrant D. Fever and sore throat
Correct Answer : C. Abdominal pain in the left upper quadrant When using the urgent vs nonurgent approach to client care , the nurse should determine that the priority finding is left upper - quadrant pain , which can indicate an enlarged spleen . An enlarged spleen can rupture , leading to internal hemorrhaging . The nurse should encourage the client to refrain from engaging in strenuous activities until the splenomegaly is resolved .
A nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago . Which of the following actions should the nurse include in the client's plan of care ? A. Flush the nephrostomy tube every 4 hours with sterile water . B. Clamp the nephrostomy tube intermittently to establish continence . C. Check the skin at the nephrostomy site for irritation from urine leakage . D. Monitor for and report any blood - tinged drainage to the provider immediately .
Correct Answer : C. Check the skin at the nephrostomy site for irritation from urine leakage. The nurse should monitor the client for complications ( e.g. bleeding , hematuria , fistula formation , infection ) , impairment of skin integrity ( e.g. inflammation , infection , bleeding , urine leakage , irritation ) , and tube obstruction . The nurse should use the aseptic technique for dressing changes and encourage oral intake but should never clamp or irrigate the nephrostomy tube without a specific prescription to do so.
A nurse is teaching a client about dietary modifications to control blood pressure . Which of the following food choices should the nurse identify as an indication that the client understands the instructions ? A. Onion soup and salad B . Vegetarian wrap with potato chips C . Grilled chicken salad with fresh tomatoes . D. Chicken bouillon and crackers
Correct Answer : C. Grilled chicken salad with fresh tomatoes . Sodium reduction helps control blood pressure . Grilled chicken salad and fresh tomatoes are free of preservatives and , therefore , are likely to be low in sodium . However , it is essential to make sure the food preparer has not added salt generously to the chicken and the salad.
A nurse is assessing a client who has an abdominal aortic aneurysm ( AAA ) . Which of the following findings indicates that the AAA is expanding ? A. Increased BP and decreased pulse rate B . Jugular vein distention and peripheral edema C. Report of sudden , severe back pain D. Report of retrosternal chest pain radiating to the left arm
Correct Answer : C. Report of sudden , severe back pain An aortic aneurysm is a weak spot in the wall of the aorta ( the primary artery that carries blood from the heart to the head and extremities ) that allows the aorta to expand and increase in diameter . Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots .
A nurse is teaching a client who is preoperative for a cystoscopy . Which of the following statements should the nurse make ? A. " You will need to keep the sutures clean after this procedure . " B . " You will be placed on your left side for this procedure . " C. " Expect to be on bed rest for 24 hr after this procedure . " D. " Expect to have pink - tinged urine after this procedure . "
Correct Answer : D. " Expect to have pink - tinged urine after this procedure . " A cystoscopy is a procedure in which a scope is inserted into the urethra to diagnose or treat bladder problems . Following the procedure , pink - tinged urine is expected .
A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self - catheterization at home after discharge . Which of the follow statements indicates that the client understands the procedure ? A. " I'll drink less water so I don't have to catheterize myself too often B. " I must use sterile technique for each of the catheterizations." C. " I should stop the catheterization when I have removed 150 mL of urine . " D. " I will perform intermittent self - catheterization every 2 to 3 hr . "
Correct Answer : D. " I will perform intermittent self - catheterization every 2 to 3 hr . " The client might initially require self - catheterization every 2 to 3 hours , with the frequency eventually increasing to every 4 to 6 hours . A longer interval can result in bladder distention and an increased risk of urinary tract infections .
A nurse is teaching a client who has a new prescription for alendronate for the treatment of osteoporosis . Which of the following statements by the client indicates an understanding of the teaching ? A. " I will take the medication in the evening . " B. " I will drink a full glass of milk with the medication . " C . " I will take the medication at mealtime . " D. " I will sit upright after taking the medication . "
Correct Answer : D. " I will sit upright after taking the medication . " A client taking alendronate should sit upright for 30 minutes after administration to prevent esophageal irritation and ulceration . Therefore , the nurse should identify this statement as indicating an understanding of the teaching .
A nurse is providing teaching about foot care to a client who has diabetes mellitus . Which of the following pieces of information should the nurse include in the teaching ? A " Wear nylon socks with shoes . " B . " Wear flip flops instead of going barefoot when outside . " C. " Apply moisturizing cream between your toes . " D. " Wash your feet daily using lukewarm water and soap . "
Correct Answer : D. " Wash your feet daily using lukewarm water and soap . " A client who has diabetes mellitus should wash the feet daily with lukewarm water and soap . The client should keep the feet clean and free from dirt, which can cause infection, and inspect the feet daily for cuts or calluses, which can develop into a foot ulcer.
A nurse is assessing a client who is receiving peritoneal dialysis . Which of the following findings should the nurse report to the provider immediately ? A. Difficulty draining the effluent B. Redness at the access site C . Fluid flowing from the catheter site D. Cloudy effluent
Correct Answer : D. Cloudy effluent A cloudy or opaque effluent indicates the client is at high risk for peritonitis , a bacterial infection of the peritoneum . Therefore , this is the priority finding for the nurse to report to the provider . Previous
A nurse is reviewing the laboratory findings of a client who has chronic kidney disease . The client reports significant persistent nausea and muscle weakness . Which of the following findings should the nurse expect ? A. Hypernatremia B. Hypomagnesemia C. Hypercalcemia D. Hyperkalemia
Correct Answer : D. Hyperkalemia A client who has chronic kidney disease can have hyperkalemia , which is a potassium level greater than 5.0 mEq / L . The expected reference range for potassium is 3.5 to 5.0 mEq / L . Other manifestations of hyperkalemia can include palpitations , dysrhythmias , nausea , and muscle weakness .
A nurse is assessing client who has acute kidney injury ( AKI ) . According to the RIFLE classification system , which of the following findings indicates that the client has end - stage kidney disease ? A < 0.5 mL / kg of urine output for 12 hr B. No urine output for 12 hr C . No urine output without renal replacement therapy for 4 to 12 weeks D. No urine output without renal replacement therapy for more than 3 months .
Correct Answer : D. No urine output without renal replacement therapy for more than 3 months In the RIFLE classification , R stands for Risk , I stands for Injury , F stands for Failure , L stands for Loss , and E stands for End - stage kidney disease . No urine output without renal replacement therapy for more than 3 months indicates end - stage kidney disease .
A nurse is caring for a client who is receiving peritoneal dialysis . The nurse should monitor the client for which of the following adverse effects ? A. Diarrhea B. Increased serum albumin C. Hypoglycemia D. Peritonitis
Correct Answer : D. Peritonitis Peritonitis is an adverse effect of peritoneal dialysis . Prevention requires using sterile technique and frequently assessing the catheter exit site . The nurse should obtain cultures of the dialysate outflow effluent ) if peritonitis is suspected .
A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx . The nurse should include which of the following topics ? ( Select all that apply . ) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises
Correct Answers : A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises The client will receive fluids and nutrition via an enteral tube while healing from the surgery . Radical neck dissection interrupts vocal communication , so the nurse should determine with the client and family how the client will prefer to communicate . Extensive resection can result in some disfigurement and permanent tracheostomy ; the nurse should help prepare the client for these changes . Swallowing can be challenging after an extensive resection . The client might require the assistance of a speech - language pathologist to provide swallowing exercises and techniques .
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder . Which of the following manifestations should the nurse expect ? ( Select all that apply . ) A. Jugular vein distension B. Moist crackles C. Postural hypotension D . Increased heart rate E . Fever
Correct Answers : A. Jugular vein distension . B. Moist crackles D. Increased heart rate The increased venous pressure due to excessive circulating blood volume results in neck vein distension . Moist crackles are an indicator of pulmonary edema that can quickly lead to death . Fluid volume excess ( hypervolemia ) is an expansion of fluid volume in the extracellular fluid compartment , which results in an increased heart rate and bounding pulses .
A nurse is providing teaching to a client who has gout and urolithiasis . The client asks how to prevent future uric acid stones . Which of the following suggestions should the nurse provide ? ( Select all that apply . ) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices
Correct Answers : A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine The nurse should inform the client that allopurinol is an antigout medication that reduces uric acid , which helps prevent uric acid stone formation , Immobility is a risk factor for stone formation ; therefore , the client should maintain a healthy lifestyle , including regular exercise . Purine increases the risk of uric acid stone formation ; organ meats , poultry , fish , red wine , and gravy are high in purine.
