MS2 Exam Two ATI Review Questions & Family Feud Questions
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations? A. Cerebellar dysfunction B. Occipital lobe dysfunction C. Increased intraocular pressure D. Macular degeneration
A
A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This finding indicates the stone is in which of the following structures? A. Ureter B. Bladder C. Renal pelvis D. Renal tubules
A
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. Widened pulse pressure B. Tachycardia C. Periorbital edema D. Decrease in urine output
A
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter
A
A nurse is caring for a client who had a cerebrovascular accident (CVA). The client appears alert and engaged during a visit but does not respond verbally to questions. The nurse should document this as which of the following alterations? A. Expressive aphasia B. Dysarthria C. Receptive aphasia D. Dysphagia
A
A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? A. Relieve the client's pain B. Encourage the client to increase fluid intake C. Monitor the client's intake and output (I&O) D. Strain the client's urine
A
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. The client rigidly extends his arms. B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.
A
A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? A. The client's ability to clear oral secretions B. The client's ability to communicate verbally C. The client's ability to move all extremities D. The client's ability to remain continent of urine
A
A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take? A. Warm the dialysate solution prior to administration B. Cleanse the catheter site using a back and forth motion, beginning at the end of the catheter and moving inward C. Place the drainage bag at the level of the client's chest D. Apply clean gloves and cleanse the client's catheter site with cold water
A
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side‑lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.
A
A nurse is caring for a client who was recently admitted to the emergency department following a head‑on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.
A
A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg
A
A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? A. Potassium and magnesium B. Calcium and bicarbonate C. Hemoglobin and hematocrit D. Arterial pH and PaCO2
A
A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. Elevated ST segments B. Absent P waves C. Depressed ST segments D. Varying PP intervals
A
A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency
A
A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority? A. Dysrhythmias B. Pink-tinged urine C. Bruising on the flank area D. Stone fragments in the urine
A
A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hr B. Limit the client's daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling urinary catheter from the client's provider D. Ambulate the client to the bathroom every 30 min
A
A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair
A
A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? A. Calcium B. Phosphorous C. Potassium D. Sodium
A
A nurse is providing discharge teaching to a client who has had a transient ischemic attack (TIA). Which of the following instructions should the nurse include? A. Reduce dietary sodium B. Decrease dietary potassium C. Restrict intake of insoluble fiber D. Limit alcohol intake to ≤3 servings per day
A
A nurse is providing teaching about degenerative complications to the partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is the priority? A. Dysphagia B. Emotional lability C. Impaired speech D. Self-care dependency
A
A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include? A. Rise slowly when standing. B. Expect urine to become dark‑colored. C. Avoid foods containing tyramine. D. Report any skin discoloration.
A
A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol
A
A nurse is teaching a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching? A. "You should complete the entire cycle of antibiotic therapy." B. "You should maintain complete bed rest until manifestations decrease." C. "You should drink 1,000 mL of fluid per day." D. "You should avoid using NSAIDs for pain."
A
A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein
A
A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommending restricting the intake of which of the following nutrients? A. Protein B. Carbohydrates C. Calcium D. Monounsaturated fats
A
A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply.) A. Hemodialysis B. Biopsy C. Immunosuppression D. Balloon angioplasty E. Surgical repair
A, B, C
A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.
A, B, C
A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.
A, B, C, D, E
A nurse is caring for a client who has experienced a right‑hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply.) A. Impulse control B. Moving the left side C. Depth perception D. Speaking E. Situational awareness
A, B, C, E
A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension
A, B, D
A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow‑up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A, B, E
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Assist the client to use cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.
A, B, E
A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a blood potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery
A, D, E
A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? A. Reduced left-sided motor function B. Difficulty with speech C. Impulsive behavior D. Neglect of the left side of the body
B
A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C. Motor loss on one side of the body D. Bleeding from the top of the scalp
B
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
B
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul
B
A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. Which of the following findings is a manifestation of bladder trauma? A. Stress incontinence B. Hematuria C. Pyuria D. Fever
B
A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? A. Insert an oral airway B. Turn the client onto a side C. Restrict movement of the client's limbs D. Place a pillow under the client's head
B
A nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor? A. Understanding speech B. Respiratory effort C. Decision-making ability D. Temperature control
B
A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Examine skin for irritation or pressure. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.
B
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
B
A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic
B
A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
B
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of the body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on the plate using the clock method. D. Place the wheelchair on the client's left side.
B
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next? A. Administer nifedipine B. Place the client in a high-Fowler's position C. Check for urinary retention D. Check for a fecal impaction
B
A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the client's ECG? A. Narrower than usual QRS complexes B. Much greater amplitude than the usual QRS complexes C. Same polarity as the usual QRS complexes D. Immediate resumption of the usual rhythm
B
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes
B
A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? A. "Expect the test to take about 3 hr." B. "You'll begin by lying still with your eyes closed." C. "You'll sleep for the duration of the procedure." D. "Expect some mild electrical shocks during the test."
B
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
B
A nurse is preparing an in-service program about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of symptoms. B. Interference with renal perfusion causes prerenal azotemia. C. Prerenal azotemia is irreversible, even in the early stages. D. Infections and tumors cause prerenal azotemia.
B
A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home? A. Blood glucose B. Blood pressure C. Daily weight D. Sensation in the feet
B
A nurse is providing dietary teaching to a client who has chronic renal failure. Which of the following food choices by the client indicates an understanding of the teaching? A. Canned soup B. Grilled fish C. Pastrami D. Peanut butter
B
A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? A. Reorient the client B. Protect the client's head C. Loosen constrictive clothing D. Turn the client onto his side
B
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."
B
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
B
A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include? A. Weight gain B. Back pain C. Vaginal discharge D. Muscle cramps
B
A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? A. "Douche after vaginal intercourse." B. "Wipe from front to back after defecation." C. "Avoid foods that are high in phosphate." D. "Add yogurt to your diet regularly."
B
A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. Which of the following prescriptions might be appropriate for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine
B
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter? A. P waves occurring at 0.16 seconds before each QRS complex B. Atrial rate of 300/min with QRS complex of 80/min C. Ventricular rate of 82/min with an atrial rate of 80/min D. Irregular ventricular rate of 125/min with a wide QRS pattern
B
A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply.) A. Decreased vision B. Pill‑rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression
B, C, D, F
A nursing is caring for a client who has a closed‑head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.
B, D
A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which of the following actions should the nurse include? (Select all that apply.) A. Provide three large balanced meals daily. B. Record diet and fluid intake daily. C. Document weight every other week. D. Offer cold fluids such as milkshakes. E. Offer nutritional supplements between meals.
B, D, E
A newly licensed nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." This statement indicates which of the following events is occurring? A. The cardioverter is being charged to the appropriate setting. B. The team should initiate CPR due to pulseless electrical activity. C. Team members cannot be in contact with equipment connected to the client. D. A time‑out is being called to verify correct protocols.
C
A nurse is assessing a client who has increased intracranial pressure and has received intravenous mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Decreased blood glucose B. Decreased bronchospasms C. Increased urine output D. Increased temperature
C
A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? A. Elevated BUN B. Bradycardia C. Headache D. Temperature 39.2°C (102.5°F)
C
A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. Inability to remember current age B. Inability to count backward C. Inability to locate eyeglasses D. Inability to recall names of family members
C
A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils
C
A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left‑hemispheric stroke? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception
C
A nurse is caring for a client during the first 72 hr following a cerebrovascular accident (CVA). Which of the following actions should the nurse take? A. Turn the client's head to the side with the head of the bed elevated 60° B. Place the head of the bed flat with pillows under the client's neck and feet C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position D. Position the client in a dorsal recumbent position with pillows under the head and knees
C
A nurse is caring for a client who displays manifestations of stage III Parkinson's disease. Which of the following actions should the nurse include? A. Recommend a community support group. B. Integrate a daily exercise routine. C. Provide a walker for ambulation. D. Perform ADLs for the client.
C
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
C
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.
C
A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response
C
A nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. Which of the following indicates that the client is meeting a successful short-term goal following this procedure? A. The client requests pain medication upon arrival from surgery. B. A chest X-ray shows consolidation in the right lower lobe. C. Urinary output is 35 to 50 mL/hr consistently. D. The client has slight abdominal distention.
C
A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? A. The client cannot name simple objects or formulate sentences or phrases. B. The client has difficulty articulating correctly due to muscle weakness of the mouth and tongue. C. The client is unable to understand words or sentences she hears. D. The client speaks words that substitute for those she intends to say.
C
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter B. Administer pain medication to the client C. Change the client's position D. Place the drainage bag above the client's abdomen
C
A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin
C
A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." . B. "You should avoid the use of CT scans with contrast.". C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management.
C
A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking an antacid when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.
C
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG B. Take a sedative the night prior to the EEG C. Thoroughly shampoo her hair prior to the EEG D. Sleep for at least 8 hr during the night prior to the test
C
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following pieces of information should the nurse include in the teaching? A. Hospitalization is required when administering each treatment. B. The maximum effect of the medication will occur in 6 months. C. Hypertension is a common adverse effect of this medication. D. Blood transfusions are needed with each treatment.
C
A nurse is providing teaching to a client who is scheduled for an electroencephalogram in the morning. Which of the following pieces of information should the nurse share? A. "You'll feel some mild electrical sensations like static electricity during the procedure." B. "Do not eat or drink anything except water after midnight." C. "Shampoo your hair before the procedure and don't use any styling products afterward." D. "It's common to have temporary short-term memory loss after the procedure."
C
A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? A. Remote B. Sensory C. Immediate D. Recall
C
A nurse responds to a call from an assistive personnel that a client just had a seizure and is unconscious. Which of the following assessments is the nurse's priority? A. Measure the client's vital signs B. Perform a neurological examination C. Check airway patency D. Assess the client for injuries
C
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine
D
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? A. Flushing of the lower extremities B. Hypotension C. Tachycardia D. Report of a headache
D
A nurse is assessing a 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
D
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
D
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take first? A. Obtain coagulation laboratory studies from the client B. Apply pneumatic compression boots to the client C. Request a referral for a speech-language pathologist D. Keep the client NPO
D
A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? A. Anticoagulant B. Plasma expanders C. H2 antagonists D. Muscle relaxants
D
A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly when ambulating. B. Complete passive range‑of‑motion exercises daily. C. Place the client on a low‑protein, low‑calorie diet. D. Give the client extra time to perform activities.
D
A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise
D
A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect? A. Spasticity of the left foot B. Negative Babinski reflex C. Ocular hypertension D. Right-sided hemiplegia
D
A nurse is caring for a client who has urolithiasis and requires further diagnostic testing after an initial test indicated hypercalcemia. Which of the following structures controls calcium concentration? A. Pancreas B. Thyroid gland C. Anterior pituitary gland D. Parathyroid gland
D
A nurse is preparing a client for an electroencephalogram (EEG). When the client asks the nurse what this test does, which of the following responses should the nurse provide? A. "An EEG measures the electric signals to your brain from hearing, sight, and touch." B. "An EEG measures the electrical activity in your muscles." C. "An EEG identifies the magnetic fields produced by electrical activity in your brain." D. "An EEG records the electrical activity of your brain cells."
D
A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest
D
A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.
D
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
D
