ATI questions exam 4

A nurse is assessing an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation?

increased BP in the arms w decreased BP in the legs

A nurse is assessing an infant. Which of the following is a clinical manifestation of a large patent ductus arteriosus?

machinery-like murmur

A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider?

yellow nasal discharge (indicator of an upper respiratory infection)

A nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

wash the hair with a mild protein shampoo (prone to hair loss or alopecia)

A nurse is providing teaching to a client about carbon monoxide poisoning. Which of the following statements by the client indicates a need for further teaching?

"I can detect the presence of carbon monoxide by a metallic odor" carbon monoxide is odorless

A nurse is teaching a patient who has nephrotic syndrome. Which of the following patient statements indicates a need for further teaching?

"I should increase my sodium intake" You want to decrease sodium!

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?

"I will add Polycose to each of my baby's bottles" increase the calories per ounce

​A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse understands that further teaching is necessary when the mother states which of the following?

"I will give my son the enzymes between meals" enzymes need to be given right before or with every meal and snack

A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and treatment. The nurse should recognize that the parent understands the child's nutritional needs when she states which of the following?

"I will make certain that pancreatic enzymes are taken w all of my child's snacks and meals"

A nurse is providing education to a school-age child who is newly diagnosed with asthma. Which of the following statements by the nurse is appropriate?

"do you know what to do if you have trouble breathing at school?"

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?

"if suspicion of abuse exists then reporting is mandatory"

A nurse is educating new parents on risk factors for sudden infant death syndrome (SIDS). Which of the following statements by a parent would indicate a need for additional teaching?

"our baby will sleep in my bed bc I am breastfeeding" baby needs to sleep separate

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching?

"your provider may recommend a daily antihistamine to help control your symptoms"

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse request the provider should see first?

A school-age child who has acute epiglottitis is drooling and has an absence of spontaneous cough.

A nurse is caring for an adolescent who has a diagnosis of acute glomerulonephritis. Which of the following should be reported immediately to the provider?

BP 162/90

A nurse is admitting an adolescent following a blunt trauma to the adolescent's abdomen. Which of the following findings should concern the nurse?

BP 92/50 mm Hg could be signs of shock or hemorrhage

A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

BUN 50 mg/dL

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder?

PDA

A charge nurse is expecting four new admissions from the emergency department and must assign each to a room. Which of the following clients should the nurse admit to the room closest to the nurse's station?

a client who has a concussion and is having periods of confusion

​A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the highest priority for care?

a client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

A nurse is triaging clients in the emergency department (ED). Which client should the nurse see first?

a client who is 28 weeks pregnant and reports slight amount of painless bleeding

A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the following clients should the nurse identify as being the highest priority?

a conscious adult with second degree burns on both lower legs; respiratory rate is > 30/min; capillary refill is < 2 seconds.

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

a dry, red rash across the bridge of the nose and on the cheeks

A premature infant has a patent ductus arteriosus (PDA). What are the expected effects after administration of indomethacin (Indocin)?

ductus arteriousus closes

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?

administer a short-acting B2 agonist (SABA)

A triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. The nurse notes a dressing on the chest and a 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?

administer oxygen via nasal cannula

A nurse is planning care for a patient who has acute glomerulonephritis related to a streptococcal infection. Which of the following interventions is appropriate to include in the plan of care?

administer prescribed antibiotics

A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for

airway obstruction

​A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care?

airway protection

​A nurse approaches a client who has just arrived at the emergency department with possible multiple facial fractures. What is the nurse's initial assessment priority for this client?

altered respirations

Following a suicide bombing at a shopping mall, an unidentified, unconscious client is admitted to the emergency department with an acute intra-abdominal hemorrhage. The nurse should recognize that consent for the surgery

can be inferred since the client is in critical condition

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

check the child's daily weight

A nurse in the emergency department is preparing to care for a client who has an altered level of consciousness and signs of alcohol intoxication. Which of the following should the nurse plan to include in the client's care?

check the client's pupil reactivity prepare the client for a CT scan obtain a urine specimen contact lab for blood sample

A nurse is caring for an adult client who has atopic dermatitis. Which of the following findings should the nurse expect?

chronic rash with thick skin

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?

connective tissue

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?

cytotoxic

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger during a farming accident. During the assessment, the nurse detects a strong smell of alcohol from the client. Which of the following data should the nurse assess for first?

date of last tetanus immunization

​A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding?

daytime symptoms occur more than twice a week minor limitations occur w normal activity PEF is greater than or equal to 80% pf the predicted value

A nurse in an emergency department is caring for a client who collapsed after playing football on a hot, sunny day. After reviewing the admission laboratory values below, the nurse should recognize that these results are consistent with which of the following? Sodium and BUN levels are elevated

dehydration

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

presence of peripheral edema (greatest risk of death from lupus nephritis)

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

respirations are unlabored

A client is admitted to the emergency room with a respiratory rate of seven per 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 28 mEq/L

respiratory acidosis

A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

tissue damage at site

​A nurse is admitting a client who has multiple trauma following a motor-vehicle crash. Shortly after admission, the client's husband arrives. He is distraught and blames himself for the accident. Which of the following is an appropriate nursing response?

"tell me more ab your feelings ab what happened to your wife"

A nurse is caring for a client who has a 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

A nurse is caring for a client who has systemic lupus erythematosus and is about to start taking hydroxychloroquine (Plaquenil) to reduce skin inflammation. The nurse should instruct the client to report which of the following as an indication of a toxic reaction to this medication?

decreased visual acuity

​A nurse is caring for a client in an urgent care center who has traumatic injuries following an assault. She sits quietly and calmly in the examination room. The nurse should recognize this behavior as which of the following reactions?

denial

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

distant heart sounds w low voltage QRS complexes on the EKG

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a gang riot. The nurse should plan to base his primary survey on which of the following?

airway, disability, and exposure for sure not sure what else!

A nurse is the triage officer in the emergency department when four clients arrive at the same time by ambulance following a factory explosion. Which of the following clients should the nurse care for first?

an unconscious adult with a sucking chest wound; respirations are 38/min; capillary refill is < 2 seconds

​A nurse in the emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following should the nurse plan to do first?

apply pressure directly over the wound

What are examples of Type I or IgE-mediated hypersensitivity reactions?

asthma angioedema anaphylactic shock urticaria

A nurse is assessing a client who is newly transferred from the emergency department. While in the emergency department, the client had a chest tube inserted in the right pleural space and attached to a chamber drainage system for a spontaneous pneumothorax. Which of the following observations should concern the nurse?

drainage of 250 mL of bright red blood in the past 2 hr

​A nurse in the emergency department is assessing a client who has multiple injuries of the abdomen. Which of the following findings require further investigation by the nurse?

ecchymosis

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

evaluate chest expansion

A clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found with this disorder?

exercise intolerance

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

exercise...exercise is okay! sunlight, pregnancy, and infections can trigger SLE

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect?

facial edema

A nurse is completing a history and physical on a 3-year-old child who is admitted for a surgical repair of Tetralogy of Fallot (TOF). Which of the following manifestations of the condition should the nurse expect?

failure to thrive clubbing polycythemia murmur

A nurse is making her plan of care for a child with an atrial septal defect. Upon assessment, the nurse expects to find:

fatigue, dyspnea, S2 heart sound is fixed and split

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that his chest moves inward during inspiration and bulges out during expiration. The nurse should suspect which of the following?

flail chest

Sudden infant death syndrome (SIDS) is the third leading cause of death in infants. At what age is the diagnosis of SIDS most likely?

from birth to 1 year of age, peaking at 2-4 months

A nurse is caring for a client who has received a blood transfusion and has an anaphylaxis reaction. The nurse understands this is a humoral immune response against invading antigens. Which of the following would further the nurses understanding?

humoral immune response is mediated by antibodies produced by B lymphocytes

A nurse in the emergency department is admitting a client with extensive burn injury who has no known medical problems. Which of the following is an expected laboratory finding in this client?

hyperkalemia

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

hypovolemia

The nurse is teaching a mother of an infant with Tetralogy of Fallot. The nurse instructs the mother to place the infant in which of the following positions if the infant suddenly becomes cyanotic and dyspneic?

in a knee-chest position

​A nurse is planning home care for a 9-year-old child who is discharged following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?

industry vs inferiority

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 the priority nursing action when the client is brought into the emergency room?

inspect mouth for signs of inhalation injuries

​A nurse is performing a neurological assessment for a client who is receiving treatment for head trauma. Which of the following will give the nurse information about the function of the third cranial nerve?

instruct the client to look up and down without moving his head observe for extraocular movements

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

low-sodium, fluid-restricted

​A client arrives at the emergency department following an explosion at a 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 for this client?

maintain a patent airway

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 caring for a child who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. To detect an electrolyte imbalance caused by corticosteroid use, the nurse should monitor the child for which of the following?

muscle weakness (d/t hypokalemia)

A nurse is caring for an infant who has congestive heart failure (CHF) secondary to a ventricular septal defect (VSD) and was brought to the clinic by the parent with a report of poor feeding. After instructing the parent about nasogastric (NG) tube feedings, the nurse evaluates that teaching has been effective when the parent states, "I will

nurse my baby for 20 min then give rest by NG tube

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?

nurses and other emergency personnel

​A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement?

obtain a set of vital signs assess adequacy of respirations assess for visceral damage stabilize head and neck

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

oliguria

You are assessing a 5-year-old who has been admitted with an acute respiratory infection. You review the chart and see the child has cystic fibrosis. What is the priority assessment/intervention?

opening and maintaining a patent airway

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

orthopnea

​A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). Which of the following would be appropriate to include in a discussion with the mother?

placing her child on the back when sleeping will decrease risk of SIDS

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

serum creatinine

​A nurse monitors a client who has a traumatic head injured. Which of the following manifestations should the nurse report immediately to the provider?

sudden sleepiness sign of increased ICP

A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will the nurse prepare the child for to confirm the diagnosis?

sweat chloride test

A school nurse interprets the peak expiratory flow rate for a child with asthma and finds that the child is in the yellow zone of the client's asthma action plan. This means which of the following?

the child should use his quick-relief inhaler the child's asthma is getting worse the child's peak flow is 50% to 79% of his best peak flow

The nurse is assessing a patient who comes to the clinic with an itching, red rash on his hands. After gathering a history, the nurse determines that the patient has developed contact dermatitis from wearing latex gloves while painting. Which description about this patient's condition is accurate?

this demonstrates a type IV allergic reaction to chemicals used in the manufacture of latex gloves

A patient has received a bone marrow transplant. Soon after the transplant, there is a rash on the patient's skin. She says her skin is itchy and she has severe abdominal pain. What best summarizes what is happening to this patient and how will she be treated?

transplanted bone marrow is rejecting her tissue; prevent with immunosuppressive agents

A patient was given an IM injection of penicillin in the gluteus maximus and developed dyspnea and weakness within minutes following the injection. Which additional assessment findings indicate that the patient is having anaphylactoid reaction?

wheezing feeling of impending doom

​An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for preserving the amputated part for possible surgical reattachment?

wrap the part in sterile dry gauze put the severed part in a dry, waterproof plastic bag prevent contact of the severed part with water