ATI Proctored Assessment

While talking with a client with a diagnosis of end stage liver disease. The nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition? A. Hyperglycemia B. Increased Bile production C. Increased blood ammonia levels D. Hypocalcaemia

C. Increased blood ammonia levels

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings? a. Excessive thrombosis and bleeding b. Progressive increase in platelet production c. Immediate sodium and fluid retention d. Increased clotting factor

d. Increased clotting factor

A client arrives at the emergency dept following an explosion at the chemical plant. He has deep partial and full-thickness chemical burns over more than 25 % of his body surface area. What is the nurse's priority intervention? a. Initiate fluid resuscitation b. Medication for pain c. Administer antibiotics d. Maintain a patent airway

d. Maintain a patent airway

During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor b. Monitor daily weight c. Assess mucous membranes d. Measures hourly urine output

d. Measures hourly urine output

During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which findings is most important for the nurse to report to the HCP? a. Decreased bowel sounds b. Apical pulse 110 beats/min c. Pale, cool, and dry extremities d. New onset of confusion and agitation

d. New onset of confusion and agitation

After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mmHg. The nurse will anticipate the administration of which of the following? a. Nitroglycerin (Tridil) b. Sodium nitroprusside (Nipride) c. Drotrecogin alpha (Xigris) d. Norepinephrine (Levophed)

d. Norepinephrine (Levophed)

Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed? A. Nitroglycerin B Nifedipine (Procardia) C Lidocaine (Xylocaine) D. Amiodarone (Cordarone)

D. Amiodarone (Cordarone)

Assessing response in an unconscious patient:

Nail bed pressure (peripheral)

Intracranial pressure

No lumbar puncture

The nurse is caring for client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40 percent. The 02 saturation measured by pulse oximeter was 83 ABG results are pH 7.31, PACO2 93mmHg, HCO3 25 meq/L. Which of the following is an appropriate action by the nurse?

Position client in high-Fowlers and encourage use of incentive spirometer and choughing.

Cranial Nerve II: Optic

Snellen test

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of the following? a. A cardiology consult b. Less frequent suctioning c. An antidysrhythmic medication d. Pre-oxygenation prior to suctioning

d. Pre-oxygenation prior to suctioning

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following is an appropriate nursing response? a. Most clients dislike the prep more than the procedure itself. b. Don't worry; you'll be sedated and just fine c. No, you shouldn't feel any pain because your rectum will be anesthetized d. You'll be sedated for the procedure and may not remember much of the procedure.

d. You'll be sedated for the procedure and may not remember much of the procedure.

Which of these findings is the best indicators that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. hemoglobin is within normal limits b. Urine output is 60 mL over the last hour c. Pulmonary artery wedge pressure (PAWP) is 10 mmHg d. Mean arterial pressure (MAP) is 55 mm Hg

b. Urine output is 60 mL over the last hour

PT & INR for Coumadin, INR 2.8

Continue medication

A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate understanding of the immunization? A. I need to get 6 shots of hep C B. Once I receive the Hep vaccine I will always been immune C. I will receive 3 injections over a period of months, which should protect me from hep B D. Hep vaccine is an oral vaccine with live attenuated Virus

C. I will receive 3 injections over a period of months, which should protect me from hep B

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? Select all that apply. a. Polyuria b. Blurred vision c. Polydipsia d. Tachycardia e. Moist, clammy skin

b. Blurred vision d. Tachycardia e. Moist, clammy skin

When caring for the patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider? (TB ch.67 Q.17) a. BP 92/56 mm Hg b. Skin cool and clammy c. apical pulse 118 beats/min d. Arterial oxygen saturation 91%

b. Skin cool and clammy

The nurse is caring for a client with chronic hep B. What will the teaching plan for this client include? A. use a condom for sexual intercourse B. Report any clay- colored stools. C. Eat a high protein diet D. Perform daily urine bilirubin checks

A. Use a condom for sexual intercourse

The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Administer oxygen B. Checks the client's vital signs C. Ventilates the client manually D. Starts cardiopulmonary resuscitation

C. Ventilates the client manually

Planning rehabilitation for a stroke patient

a. Assess functional status before developing plan b. Walking, speaking, eating, ADLs

The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client's BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action? a. Recheck the BP and call the doctor b. Decrease the infusion rate and recheck the blood pressure in 5 minutes c. Stop the medication and keep the IV open with D5W. d. Assess the client's tolerance of the current level of BP

b. Decrease the infusion rate and recheck the blood pressure in 5 minutes

A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what his medication will do, which of the following is an appropriate nursing response? a. It helps convert atrial fibrillation to sinus rhythm b. Is dissolves clots in the bloodstream c. It slows the response of the ventricles to the fast atrial impulses d. It prevents strokes in clients who have atrial fibrillation

d. It prevents strokes in clients who have atrial fibrillation

T2-T3

Paraplegia

HbA1c considerations for about 3 months of glucose monitoring

a. less than 6% for nondiabetic b. diabetic controlled should be less than 7%

When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome? A. Increased blood pressure B. Increased urine output C. Decreased pain D. Decreased PVCs

B. Increased urine output

Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? A. It is used to lower your blood pressure B. It is used to treat anemia C. It will help to increase the potassium levels in your body D. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity

B. It is used to treat anemia

A client arrives at the emergency department with deep partial thickness and burns over 15% of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate for this client? Select all that apply A. Cleaning the burns with hydrogen peroxide B. Covering the burns with saline-soaked towels C. Starting an I.V. infusion of lactated Ringer's solution D. Placing ice directly on the burn areas E. Administering 6 mg of morphine I.V. F. Administering tetanus prophylaxis as ordered

C. Starting an I.V. infusion of lactated Ringer's solution E. Administering 6 mg of morphine I.V. F. Administering tetanus prophylaxis as ordered

A client comes into the ER with complains of midsternal chest pain radiating to the neck and left arm which is unrelieved by sublingual nitroglycerin. An electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to immediately notify the physician? A. PR impulse 0.20 sec B. Tachycardia rate of 125 beat of premature C. premature ventricle beat D. An ST segment elevation from the isoelectric baseline.

D. An ST segment elevation from the isoelectric baseline.

The nurse is caring for hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit?

The client who has just been admitted, has severe diarrhea, and is febrile.

The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea? a. Decreased breath sounds are heard over the left side of the chest b. Increased rhonchi are present at the lung bases bilaterally c. Ventilator pressure alarm continues to sound d. Client is able to speak and coughs excessively

a. Decreased breath sounds are heard over the left side of the chest

A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders by the health care provider will the nurse question? a. Give furosemide (Lasix) 40 mg IV b. increase normal saline infusion to 150 mL/hr c. Administer hydrocortisone (SoluCortef) 100 mg IV d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr

a. Give furosemide (Lasix) 40 mg IV

What is the desired action of dopamine (Intropin) when administered in the treatment of shock? a. It increases myocardial contractility b. It is associated with fewer severe allergic reactions c. It causes rapid vasodilation of the vascular bed d. It supports renal perfusion by dilation of the renal arteries

a. It increases myocardial contractility

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a. Large incisions will be made in the eschar to improve circulation b. I can call the doctor back here if you want me to c. A piece of skin will be removed and grafted over the burned area d. Dead tissue will be surgically removed

a. Large incisions will be made in the eschar to improve circulation

The nurse is obtaining a health history from a client who is visiting the clinic with complaints of a severe headache. The client provides the following data to the nurse based on a review of systems. The nurse identifies the following as a modifiable risk for stroke? Select all the apply. a. Smoking b. Alcohol consumption c. Decreased physical activity d. Obesity

a. Smoking b. Alcohol consumption c. Decreased physical activity d. Obesity

The nurse is caring for a client who is receiving a blood transfusion. The transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and headache and is increasingly restless. What is the first nursing action? a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution b. Slow the infusion and evaluate the vital signs and the client's history of tranfusion reactions c. Slow the infusion of blood and begin infusion of normal saline solution from the Y connector. d. Recheck the unit of blood for correct identification numbers and crossmatch information

a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal saline solution

The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a. The nurse uses latex gloves when applying antibacterial cream to a burn wound b. The float nurse obtains burn cultures when the patient has a temp of 101* F c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing change d. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an elevated serum glucose

a. The nurse uses latex gloves when applying antibacterial cream to a burn wound

The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication? a. Tremors and central nervous system stimulation b. Tachycardia and chest discomfort c. Development of oral candidiasis d. An increase in blood pressure

a. Tremors and central nervous system stimulation

If dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should plan to administer intermediate-acting insulin (Humulin N) 40 units SQ to the client between? a. 5:00 and 5:30 am b. 6:30 and 7:00 am c. 9:30 and 10:30 am d. 11:00 and 11:30 am

b. 6:30 and 7:00 am

The client is admitted the ED with chest trauma. Which signs and symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax? a. Bronchovesicular lung sounds and friction rub b. Absent breath sounds and tachypnea c. Nasal flaring and lung consolidation d. Symmetrical chest expansion and bradypnea

b. Absent breath sounds and tachypnea

A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect? a. Decreased brain natriuretic peptide (BNP) b. Elevated central venous pressure (CVP) c. Decreased pulmonary pressure d. Increases urinary output

b. Elevated central venous pressure (CVP)

A client with diabetes mellitus experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which substance? a. Glucose b. Ketones c. Glucagon d. Lactic dehydrogenase

b. Ketones

A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. encourage the patient to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the patient's resp. rate d. Reposition pt in high-Fowler's position and reassess breath sounds

b. Notify the HCP and prepare for endotracheal intubation

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? a. Hemiparesis of the client's left arm and apraxia. b. Paralysis of the right side of the body and ataxia. c. Homonymous hemianopsia and diplopia. d. Impulsive behavior and hostility toward family.

b. Paralysis of the right side of the body and ataxia.

A client with acute kidney injury has a serum potassium level of a 6.0 mEq/L. The nurse should plan which action as accordingly? a. Check the sodium level b. Place the client on a cardiac monitor c. Encourage increased vegetables in the diet d. Allow an extra 50 mL of fluid intake to dilute the electrolyte concentration

b. Place the client on a cardiac monitor

A group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is priority nursing action when the client is brought to the ED? a. cover the burned area with sterile gauze b. inspect mouth for signs of inhalation c. administer intravenous pain medication d. draw blood for a CBC

b. inspect mouth for signs of inhalation

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the clients morning blood glucose level as 210mg/dL instead of 120mg/dL. Based o;n this error, she administered the insulin dose appropriate for a reading over 200 mg/ dL before the clients breakfast. Which of the following error? a. give the client 15 to 20 g of carbohydrates b. monitor the client for hypoglycemia c. complete an incident report d. notify the nurse manager

b. monitor the client for hypoglycemia

A nurse is caring for a client following a CT scan with dye who suffered from an anaphylactic reaction. Which of the following conditions requires a priority nursing response? a. urticaria b. stridor c. tachypnea d. angioedema

b. stridor

A nurse observing a close chest tube drainage system is postop 1 day thoracotomy? Continue bubbling in the suction chamber? a. check the control outlet against the wall b. observe all the connection tubing c. Continue to monitor client respiratory status d. Notify MD of the oxidation

c. Continue to monitor client respiratory status

A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations indicate a complication that requires notifying the provider immediately? a. Serosanguineous drainage from the puncture site b. Discomfort at the puncture site c. Increased heart rate d. Decreased temperature

c. Increased heart rate

Which interventions will the nurse include in the plan of the care for a patient who has cardiogenic shock? a. Avoid elevating head of bed b. Check temperature every 2 hours c. Monitor breath sounds frequently d. Assess skin for flushing and itching

c. Monitor breath sounds frequently

What electrocardiogram (ECG) changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? a. Prolonged PR interval b. Wide QRS complex c. ST-segment elevation or depression d. Tall, peaked T waves

c. ST-segment elevation or depression

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. cool clammy skin b. inspiratory crackles c. apical heart rate of 48 beats/min d. temperature 101.2* F

c. apical heart rate of 48 beats/min

A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system? a. auscultate cuff blood pressure b. palpate pulse pressure c. obtain a central venous pressure d. monitor the pulmonary artery pressure

c. obtain a central venous pressure

A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. Raise the foot of the bed to a 90 degree angle b. Remove the dressing to inspect the wound c. Prepare to insert a central line d. Administer oxygen via nasal cannula

d. Administer oxygen via nasal cannula

Which assessment is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids is used in the first 24 hours following a burn injury? a. 5% dextrose in water b. 5% dextrose in normal saline c. normal saline d. lactated ringers

d. lactated ringers

The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement. Select all A. Assess the client's level of consciousness B. Monitor clients urine output C. Perform passive range of motion exercise D. Maintain intravenous fluids as ordered E. Place the client with the HOB flat

A. Assess the client's level of consciousness B. Monitor clients urine output C. Perform passive range of motion exercise D. Maintain intravenous fluids as ordered

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of a headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? A. Notify the physician B. Monitor the client C. Elevate the head of the bed D. Medicate the client for nausea

A. Notify the physician

An older adult client comes into ER stating that he has no appetite, is nauseated, his heart feels funny and has noticed a haziness in his vision. The client states that he has been taking an antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms, what would be the priority nursing action? A. Obtain an order for an EKG and serum potassium and digitalis levels B. Perform a neurological assessment to determine whether he has one side weakness. C. Assess lungs for decreased breath sounds and/or adventitious breath sounds. d. Obtain an order for an EKG

A. Obtain an order for an EKG and serum potassium and digitalis levels

The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16. Atropine is administered IV push. What nursing assessment indicates a therapeutic response to the medication? A. Pulse rate has increased to 70 beats/min B. systolic BP has increased by 20 C. pupils are dilated D. oral secretions have decreased

A. Pulse rate has increased to 70 beats/min

The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients. Which client should be assess first? A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent. B. A client who is in heart failure and has gained 2 pounds in the last 24 hours. C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial premature

A. a client who has just returned from a coronary artierogram with placement of an intracoronary stent.

The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply A. presence of a thrill on palpation over the fistula B. Absence of a bruit on auscultation over the fistula C. Presence of a pulse in the extremity below the fistula D. Complaints of tingling or discomfort in the extremity E. Warm hand and fingers in the extremity in which the fistula is located

B. Absence of a bruit on auscultation over the fistula, D. Complaints of tingling or discomfort in the extremity

The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse expect to assess that supports the diagnosis of pneumothorax? A. Bronchovesicular lung sounds and friction rub B. Absent breath sounds and tachypnea C. Nasal flaring and lung consolidation D. Symmetrical chest expansion and bradypnea

B. Absent breath sounds and tachypnea

A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mm hg. Which drugs does the nurse expect the physician to order for this client? A. Lidocaine (Xylocaine) B. Atropine sulfate C. Isoproterenol hydrochloride (Isuprel) D. Epinephrine

B. Atropine sulfate

A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply A. Clamping the chest tube intermittently B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates. E Taping the connection between the chest tube and the drainage system.

B. Changing the client's position frequently C. Maintaining the collection chamber below the client's waist D. Adding water to the suction control chamber as it evaporates. E Taping the connection between the chest tube and the drainage system.

A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock? A. Spastically, neuromuscular irritability, hyperreflexia B. Flaccidity and lack of sensation below the level of spinal cord lesion. C. Automatic dysreflexia with neurogenic bladder symptoms D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion.

B. Flaccidity and lack of sensation below the level of spinal cord lesion.

A client has a low sodium diet and reduce fluid intake to choose lunch. A. Tuna sandwich on wheat bread, can of cocktail fruit, salad, and soda B. Grill chicken sandwich on white bread, apple, salad, and ice tea C. Grill cheese sandwich, tomato soup D. Ham and bean

B. Grill chicken sandwich on white bread, apple, salad, and ice tea

A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don't know how I will tolerate pregnancy because I have lupus. Which response is best? A. Most women find that they feel better when they are pregnant B. How long have you been in remission? C. Women with lupus frequently have slightly longer gestation D. It's best to become pregnant within the first 6 months of diagnosis

B. How long have you been in remission?

A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the nurse expect to note on assessment of the client? Select all A. Constipation B. Muscle twitches C. Hypoactive bowel sounds D. Hyperactive deep tendon reflexes E. Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG

B. Muscle twitches D. Hyperactive deep tendon reflexes E. Positive Trousseau's sign and positive Chvostek's sign F. Prolong ST interval and QT interval on ECG

The nurse is administering alteplase to a client who has been diagnosed with acute coronary syndrome. What are important nursing implications for this medication? A. Monitor the ECG for dysrthymias B. Place the client on bleeding precautions C. Monitor urine output hourly D. Monitor for activity tolerance

B. Place the client on bleeding precautions

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A. Confirm that the ventilator settings are correct B. Verify that the ventilator alarms are functioning properly C. Assess the respiratory status and pulse oximeter reading. D Monitor the clients arterial blood gas results

C. Assess the respiratory status and pulse oximeter reading.

A nurse assess a client who 8 score using the Glasgow coma scale to elevate of consciousness. Describe the score. A. Reflex alert client B. Need of total nursing caring C. Client in deep coma D. Stable neurological status

C. Client in deep coma

A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings? A. Stroke B. Epileptic Seizure C. Decorticate posturing D. Decerebrate posturing

C. Decorticate posturing

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin. B. Obtain a STAT electrocardiogram C. Have the client sit down immediately D. Assess the clien'ts vital signs.

C. Have the client sit down immediately

The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an important nursing measure at this time? A. Measure urinary output hourly and maintain continuous cardiac monitoring B. Encourage client to perform slow pressure exercise of the affected side to promote circulation. C. Maintain pressure over catheter insertion site and determine distal circulation status. D. Evaluate apical pulse and determine presence of pulse deficit.

C. Maintain pressure over catheter insertion site and determine distal circulation status.

What ECG changes would reflect myocardial ischemia in a client who has been admitted for observation after experiencing an episode of chest pain? A. Prolonged PR interval B. Wide QRS complex C. ST-Segment elevation or depression D. Tall, peak T-waves

C. ST-Segment elevation or depression

A client begins complains of chills and discomfort after about 50ml of blood has packed red blood cells. The best nursing action at this time is to A. Discontinue the transfusion and move the IV and restart IV transfusion at another site. B. Compare the VS now and what they were before the transfusion begin C. Stop the transfusion and maintain a patent line with normal saline solution and new tubing D. slow down the transfusion blood and dilute with normal saline solution

C. Stop the transfusion and maintain a patent line with normal saline solution and new tubing

A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following: A. Dialited pupils B. Sudden vomiting and diarrhea C. drop in BP and pulse D. Diaphoresis above the level of the lesion

D. Diaphoresis above the level of the lesion

A nurse admitted morphine 2 mg IV push after client report pain and evaluate client 15 min. later injection. Which follow adverse effect? A . pain scale level of 6 to 4 B. sleepy but arouse when name call C. O2 sat 94% D. RR 8 bpm

D. RR 8 bpm

A client admit to hospital report recurrent flank pain, nausea, and vomiting within 24 hours. Which of the following priority nursing action? A. Administered pain medication B. Monitor intake and output C. Administered antiemetics D. Strain urine

D. Strain urine

After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain. d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hr

a. A patient with smoke inhalation who has wheezes and altered mental status

A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first? a. Administer acetaminophen (Tylenol) PO. b. Administer ibuprofen (Motrin) PO. c. Draw coagulation study blood work in the AM d. Give morphine sulfate IV

a. Administer acetaminophen (Tylenol) PO.

The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which intervention should the nurse implement? Select all that apply a. Assess the client's level of consciousness b. Monitor the client's urine output c. Perform passive range of motion (ROM) exercise d. Maintain intravenous fluids as ordered

a. Assess the client's level of consciousness b. Monitor the client's urine output c. Perform passive range of motion (ROM) exercise d. Maintain intravenous fluids as ordered

The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present? a. CVP of 3 cm H20 and urine output of 20 mL/hr b. Jugular vein distention with the head elevated 45 degrees c. Chest tube drainage of 50 mL/hr in the first 2 hours d. Persistent increased BP and increased pulse pressure

a. CVP of 3 cm H20 and urine output of 20 mL/hr

The diabetic educator is teaching a class on diabetes Type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. a. Take diabetic medication even if unable to eat the client's normal diabetic diet. b. If unable to eat, drink liquids that are equal to the client's normal caloric intake. c. It is not necessary to notify the health-care provider if ketones are in the urine. d. Test blood glucose levels and test urine ketones once a day and keep a record. e. Call the health-care provider if glucose levels are higher than 180 mg/dL.

a. Take diabetic medication even if unable to eat the client's normal diabetic diet. b. If unable to eat, drink liquids that are equal to the client's normal caloric intake. e. Call the health-care provider if glucose levels are higher than 180 mg/dL.

Sengstaken-Blakemore tube prevents bleeding (esophageal varices) a. Triple lumen b. Have scissors at the bedside c. Provide oral and nasal care every 3 hours d. Used to reduce bleeding

a. Triple lumen b. Have scissors at the bedside c. Provide oral and nasal care every 3 hours d. Used to reduce bleeding

A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to extubate her within the next 24 hour. Which of the following is an important criterion for extubating the client? a. Ability to cough effectively b. Adequate tidal volume without manually assisted breaths c. No indication of infection d. No need for supplemental oxygen

b. Adequate tidal volume without manually assisted breaths

A nurse is caring for a female client who came in to the ED reporting SOB and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 mmHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Monitor for pulmonary embolism

b. Administer oxygen via face mask

The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the desired effect? a. Chest pain is completely relieved b. Client performs activities of daily living without chest pain c. Pain is controlled with frequent changes of patch d. Client tolerates increased activity without pain

b. Client performs activities of daily living without chest pain

A client comes into the ED reporting nausea and vomiting that worsens when lying down and without relief from antacids. The provider suspects acute pancreatitis. Which of the following lab test results should the nurse expect to see if the client has acute pancreatitis? a. Decreased WBC b. Increased serum amylase c. Decreased serum lipase d. Increased serum calcium

b. Increased serum amylase

A nurse is caring for a client who came the emergency dept reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is a. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues b. A protein whose levels reflect the risk for coronary artery disease c. A heart muscle protein that appears in the bloodstream when there is damage to the heart d. A protein that helps transport oxygen throughout the body

c. A heart muscle protein that appears in the bloodstream when there is damage to the heart

Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has: a. A heart rate of less than 120 beats/min b. Urine output of at least 30 mL/hr. c. Received adequate anticoagulation d. Been receiving adequate IV fluid replacement

d. Been receiving adequate IV fluid replacement

A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? a. Age of the client b. Associated medical history c. Location of the burn d. Cause of the burn

d. Cause of the burn

The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour. The nurse would interpret these findings as suggestive of which pathophysiology? a. Reduction of circulation to the coronary arteries, this increasing the preload b. Decreased glomeruli filtration rate, resulting in volume overload c. Stimulation of the sympathetic nervous system, causing severe vasoconstriction d. Decrease in the cardiac output and inadequate tissue perfusion

d. Decrease in the cardiac output and inadequate tissue perfusion