Ati questions

.A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C. Increased blood pressure from 112/68 to 120/72 mm Hg. D. Increased heart rate from 68 to 72/min.

A

.A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? A. Client report of low back pain B. Client report of tinnitus C. A productive cough D. Distended neck veins

A

.A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? A. Stop the infusion of blood. B. Inform the provider. C. Obtain a urine specimen. D. Notify the laboratory

A

.A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy? A. Hyperglycemia B. Aspiration C. Diarrhea D. Stomatitis

A

.A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia B. Ataxia C. Photosensitivity D. Jaundice

A

.A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi-Fowler's position.

A

.A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs. B. Request a dietitian consult. C. Suggest that the client rests before eating the meal. D. Request an order for an antiemetic.

A

.A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? A. Furosemide B. Nitroglycerin C. Metoprolol D. Spironolactone

A

.A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medications should the nurse prepare to administer? A. Fab antibody fragments B. Flumazenil C. Acetylcysteine D. Naloxone

A

.A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? A. Decreased blood pressure B. Increase of HDL cholesterol C. Prevention of bipolar manic episodes D. Improved sexual function

A

.A nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make? A. "This test will tell your doctor how your kidneys are functioning." B. "You'll have to ask your doctor." C. "This test will tell if you have severe renal impairment or a disease." D. "We'll find out if any medications, such as steroids, are interfering with your kidney function."

A

.A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings? A. The client is experiencing premature atrial contractions. B. The client has a decreased oxygen saturation level. C. The client has bilateral wheezes. D. The client has lower leg edema.

A

.A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses? A. Urticaria B. Fever C. Fluid overload D. Hemolysis

A

.A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses? A. Urticaria B. Fever C. Fluid overload D. Hemolysis

A

.A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg

A

.A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching? A. "I have started taking ginger root to treat my joint stiffness." B. "I take this medication at the same time each day." C. "I eat a green salad every night with dinner." D. "I had my INR checked three weeks ago."

A

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) 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 A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A

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

A

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

A

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright

A

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A. Vitamin K B. Heparin C. Warfarin D. Ferrous sulfate

A

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? A. Potassium B. Albumin C. Cortisol D. Bicarbonate

A

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority? A. Stopping the transfusion B. Covering the client with a blanket C. Notifying the provider D. Assessing the client's skin for a rash

A

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Sodium 126 mEq/L B. Potassium 3.6 mEq/L C. Magnesium 1.9 mEq/L D. Chloride 99 mEq/L

A

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? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? A. 25 mg/dL B. 13 mg/dL C. 10 mg/dL D. 18 mg/dL

A

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? A. Potassium 2.9 mEq/L B. Phosphorous 4.5 mEq/L C. Sodium 145 mEq/L D. Calcium 8.2 mg/dL

A

.A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity

B

.A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia

B

.A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? A. Notify the provider. B. Stop the infusion. C. Collect a urine sample from the client. D. Return the platelet bag and tubing to the blood bank

B

.A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect? A. Decreased creatinine level B. Hyperkalemia C. Hypomagnesaemia D. Increased glomerular filtration rate (GFR)

B

.A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Friction rub

B

.A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hypernatremia B. Hyperuricemia C. Hypercalcemia D. Hyperchloremia

B

.A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take? A. Administer 50,000 units of heparin by IV bolus every 12 hr. B. Check the activated partial thromboplastin time (aPTT) every 4 hr. C. Have vitamin K available on the nursing unit. D. Use IV tubing specific for heparin sodium when administering the infusion.

B

.A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation. B. Administer oxygen via face mask. C. Prepare to administer a sedative. D. Assess for indications of pulmonary embolism.

B

.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? A. PR interval B. QT interval C. ST segment D. QRS complex

B

.A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding? A. The drip chamber with filter is filled completely with blood. B. The packed RBCs are connected by Y tubing to normal saline. C. The blood has been infusing steadily for 5 hr with no client symptoms. D. A medication is being administered IV through the injection site closest to the client.

B

.A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe client's respiratory status. B. Elevate the head of the client's bed 30° to 45°. C. Monitor intake and output every 8 hr. D. Check residual volume every 4 to 6 hr

B

.A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin fold

B

.A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? A. "I should consume most of the fluid during the evening." B. "I will make a list of my favorite beverages." C. "I will put beverages in large containers to give the appearance of drinking a lot." D. "I will not add ice cream to the amount of fluid intake."

B

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria

B

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A. Increased heart rate B. Increased urine output C. Decreased blood pressure D. Decreased blood glucose level

B

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? A. Dry, hacking cough B. Hepatomegaly C. Dizziness D. Crackles in the lungs

B

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? A. Obtain the client's blood glucose every 12 hr. B. Change the IV tubing every 24 hr. C. Change the IV site dressing every 4 days. D. Weigh the client every other day.

B

A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take? A. Notify the provider. B. Continue to monitor the client. C. Provide oral rehydration fluids. D. Perform a bladder scan at the bedside

B

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin? A. Decreased blood pressure, rapid pulse B. Headache, restlessness C. Pain and tingling at the access site D. Muscle cramps, chest heaviness

B

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. Elevate the client's feet. B. Increase the client's IV fluid rate. C. Initiate a dopamine IV infusion for the client. D. Administer a unit of packed RBC

B

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? A. Hemoglobin (Hgb) B. Prothrombin time (PT) C. Bleeding time D. Activated partial thromboplastin time (aPTT)

B

A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer's solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% in 0.45% sodium chloride

B

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet? A. Cooked cabbage B. Dried apricots C. Ripe bananas D. Ice cream

B

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing B. Dyspnea C. Bradycardia D. Vomiting

B

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? A. The laboratory values are within the expected reference range. B. The laboratory values are prolonged. C. The laboratory values are decreased. D. The laboratory values are the same as the previous test values.

B

A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching? A. "I will rest for at least 30 minutes before eating." B. "I will take my bronchodilators after meals." C. "I will eat five or six small meals each day." D. "I will choose foods that are not gas-forming."

B

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling 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? A. Bounding pulsations B. Irregular pulsations C. Tachycardia D. Bradycardia

B

.A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. Movement of the ET tube into the right main bronchus D. Infection of the vocal cords

C

.A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Glucose 102 mg/dLPotassium 3.6 mEq/L BUN 18 mg/dLChloride 105 mEq/L Creatinine 0.7 mg/dL A. Renal failure B. Low-protein diet C. Dehydration D. Syndrome of inappropriate antidiuretic hormone (SIADH)

C

.A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

C

.A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft? A. Measure the client's blood pressure to ensure it is higher in the left arm than the right. B. Check the brachial and radial pulses of the left arm simultaneously. C. Auscultate the site for a bruit. D. Auscultate the antecubital fossa using a Doppler stethoscope

C

.A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction? A. The first 2 min B. The final 2 min C. The first 15 min D. The final 15 min

C

.A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine

C

.A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight gain C. Breathlessness D. Distended abdomen

C

.A nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. Which of the following interventions is the priority? A. Collect a urine specimen. B. Administer 0.9% sodium chloride through the IV line. C. Stop the transfusion. D. Notify the blood bank.

C

.A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving a vitamin K deficiency."

C

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A. "I am gaining weight." B. "I am constipated." C. "My vision seems yellow." D. "My tongue is red and beefy."

C

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? A. Bulging anterior fontanel B. Bradypnea C. 13% weight loss D. Capillary refill 3 seconds

C

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion? A. Skin color B. Fluid intake C. Temperature D. Hemoglobin level

C

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A. Hyperactive bowel sounds B. Increased urinary output C. Rigid abdomen D. Frequent bowel movements

C

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? A. Offer the client a light snack. B. Measure the client's blood pressure. C. Measure the client's apical pulse. D. Weigh the client.

C

A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide? A. Bicarbonate B. Carbon dioxide C. Potassium D. Phosphate

C

A nurse is caring for a client who is taking montelukast. Which of the following outcomes indicates a therapeutic effect of the medication? A. The client experiences less muscle pain. B. The client's seizure threshold is reduced. C. The client experiences an increased ease of breathing. D. The client's platelet count is increased.

C

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? A. Ventricular depolarization B. Slow repolarization of ventricular Purkinje fibers C. Atrial depolarization D. Early ventricular repolarization

C

A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction? A. Flushing B. Dyspnea C. Hypotension D. Vomiting

C

.A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. Pigeon B. Funnel C. Kyphotic D. Barrel

D

.A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions

D

.A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have? A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.49, HCO3 30, PaCO2 40 C. pH 7.26, HCO3 24, PaCO2 46 D. pH 7.26, HCO3 14, PaCO2 30

D

.A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D

.A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor? A. Hypervolemia B. Hypertension C. Hypokalemia D. Hypoglycemia

D

.A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.

D

.A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduces inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions

D

.A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicates a need for clarification? A. "I will enjoy eating cantaloupe for my morning snack." B. "I can easily add baked potatoes to my diet." C. "Eating yogurt will be a new experience." D. "Adding pecans will be a change I can readily make."

D

.A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? A. When the client has finished eating lunch B. When the client states he is ready to start the infusion C. 2 hr after obtaining blood from the blood bank D. As soon as the nurse can prepare the client and the administration set

D

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough

D

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? A. "I can walk a mile a day." B. "I've had a backache for several days." C. "I am urinating more frequently." D. "I feel nauseated and have no appetite."

D

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. B. Administer prescribed analgesic medication. C. Encourage coughing and deep breathing. D. Raise the head of the bed.

D

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? A. Epinephrine B. Atropine C. Protamine D. Vitamin K

D

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Febrile B. Allergic C. Acute pain D. Hemolytic

D

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Collect a urine specimen for culture and sensitivity. B. Continue routine care because the results are within the expected reference range. C. Decrease the IV fluid infusion rate and limit oral fluid intake. D. Evaluate urine for amount and for specific gravity

D

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment? A. Breast cancer survivor for 8 years B. Pacemaker C. 65-years of age D. Alcohol use disorder

D

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.

D

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following? A. 2 hr B. 6 hr C. 8 hr D. 4 hr

D

A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs? A. To prevent postoperative hypotension B. To determine how the client will tolerate the procedure C. To assess the client's pain level D. To establish a baseline for postoperative assessment

D

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take? A. Check the unit of blood with an assistant personal (AP) B. Premedicate the client with an antiemetic. C. Plan to infuse the unit of blood over 6 hr. D. Remain with the client for the first 15 minutes of the transfusion.

D

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation

D

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? A. Withholding the medication if the heart rate is above 100/min B. Instructing the client to eat foods that are low in potassium C. Measuring apical pulse rate for 30 seconds before administration D. Evaluating the client for nausea, vomiting, and anorexia

D

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport B. A client who has a prescription for discharge C. A client who received oral pain medication 30 min ago D. A client who told an assistive personnel he is short of breath

D

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? A. Furosemide B. Hydrochlorothiazide C. Metolazone D. Spironolactone

D

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? A. Client is currently prescribed spironolactone. B. Client has a history of alcohol abuse disorder. C. Client reports drinking 3.5 to 4 L of water each day. D. Client has an NG tube to gastric suction.

D

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes.

D