ATI practice exam
a nurse is reviewing the laboratory data on a client who has new prescription for heparin for treatment of a PE. Which of the following data should the nurse report to the provider?
platelets 74,000/mm3
a nurse is caring for a client who is scheduled for an exercise stress test. which of the following comments made by the client should indicate to the nurse that the client required further teaching?
"I'll take my heart medications the morning of my test."
a nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
"It's okay to feel scared. Let's talk about what you are afraid of."
a nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear anti embolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
"they improve your circulation to keep blood from pooling in your legs."
a nurse is assessing a client who has ineffective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?
dyspnea, tachycardia, or cough
a nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?
a chest tube
a nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
abnormally prominent U wave
a nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. 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?
administer oxygen via nasal cannula
a client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
anti platelet aggregate - used to decrease blood clotting - reduce risk of second heart attack or stroke - reduce thrombus formation
a nurse is caring for a client who just had a cardiac catheterization. which of the following nursing interventions should the nurse include in the client's plan of care?
check peripheral pulses in the affected extremity keep the client's hip and leg extended have the client remain in bed up to 6 hr
a nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
continue to monitor the client's respiratory status
a nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. which of the following actions is the nurse's priority?
defibrillation
the nurse is caring for a post op client who has a chest tube connected to suction and water seal drainage system. which of the following indicates to the nurse that the chest tube is functioning properly?
fluctuation of the fluid level within water seal chamber
a nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
have the client wear a mask
a nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?
hepatomegaly or liver enlargement
a nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
hypotension - a CCB w/ adverse effect of hypotension
while performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
impaired tissue perfusion
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
increased heart rate increased blood pressure increased respiratory rate
a nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. if the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?
irregular pulsations
a nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
keep the drainage system below the level of the client's chest at all times
a nurse is performing hygiene for a client who has pneumonia and positions the client on his left side in trendelenburg position. from which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?
lateral segment on the right lower lobe (head lower than feet - to drain the lateral segment of the right lower lobe)
a nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?
massaging her legs - can cause blood clot to detach and become an embolus
a nurse is caring for a client who has the following arterial blood gas results: HCO3: 18 mEq, PaCO2: 28 mm Hg, and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?
metabolic acidosis
a nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?
night sweats low-grade fever blood in the sputum
The nurse asks a client who is about to have a cardiac cathertization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?
notify the provider of the client's allergy
A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. when the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?
prevents dysrhythmias it delays the conduction in heart and reduces automaticity of heart tissue
a nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following lab values should the nurse monitor for a therapeutic effect of warfarin?
prothrombin time (PT)
A client is admitted to the emergency room with a respiratory rate of 7/min. ABGs reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH: 7.22 PaCO2: 68 mm Hg Base excess: -2 PaO2: 78 mm Hg Saturation: 80% Bicarbonate: 26 mEq/L
respiratory acidosis
a nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB ?
sputum culture for acid-fast bacillus
a nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itches and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?
stop the infusion
a nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
suction two to three times with a 60 second pause between passes to prevent hypoxia
A nurse is caring for a client who has atrial fibrillation and is receiving heparin. which of the following findings is the nurse's priority?
the client experiences sudden weakness of one arm and leg (risk of stroke)
a nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?
widened QRS complexes
a nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues."
a nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5mg/kg/dose subcutaneous every 12 hr. The client weighs 245 lbs. how many mg should the nurse administer per dose? round answer to the nearest whole number
167 mg per dose
a nurse is caring for a client who has cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
Atropine
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 98.8 F , pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. which of the following vital signs should the nurse re-measure ?
Blood pressure
a nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarrin?
Saw palmetto Glucosamine Gingjo biloba
a nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?
PT 45 seconds normal: 11-12.5 seconds
A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?
QT interval
a nurse is caring for a client who is 1-day post op following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
Verify that the suction regulator is on and check the tubing for leaks
a nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?
Vitamin K (reverses warfarin)
a nurse is instructing a client who is newly diagnoses with pulmonary tuberculosis (TB) about the use of anti tubercular medications. which of the following info should the nurse include in the teaching?
a typical course of treatment involves 6-9 months of consistent medication use
a nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
administer oxygen therapy - risk of PE is hypoxemia and cyanosis
a nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a PE?
assess legs for redness apply elastic compressions stockings perform passive range of motion exercises
a nurse is admitting client who reports chest pain. Client admitted with chest pain. client is diaphoretic and short of breath. Client states, "pain started when I began raking leaves in my yard." Pain "radiates to the left arm and is a sharp pain." Cardiac enzymes indicate client is experiencing myocardial infarction. Provider notified and to prepare the client for cardiac cathererization immediately. The nurse is preparing the client for the cardiac catherterization. Which of following actions should the nurse take?
confirm the client's allergies obtain the client's vital signs witness the client's signature on the informed consent form
a nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
different apical and radial pulses
a nurse is assessing a client who has a pneumothorax with a chest tube in place. for which of the following findings should the nurse notify the provider?
movement of the trachea toward the unaffected side
a nurse is reviewing the arterial blood gas values of client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
pH below 7.35
a nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. the nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
pacemaker spikes before each QRS complex
a nurse is planning care for a client following a cardiac cauterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
perform neuromuscular checks with vital signs
a nurse is completing discharge planning for a client who has bacterial endocarditis. the client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?
peripherally inserted central catheter
