ATI UNIT 5 REVIEW

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? select all that apply a. check VS before transfusion b. insert IV with a 19 g needle c. prime the blood tubing with dextrose 5% in water d. transfuse the blood product within 5 hr after removing it from refrigeration e. check the exp date of the blood product with a second nurse

A, B, E

A nurse is caring for a client Which of the following at 1015 requires further action? a. o2sat b. resp rate c. low back pain d. urine color e. BP

B, C, D, E

A nurse is caring for a clinet who is receiving 2 units of packed RBCs Which of the following actions should the nurse take? a. insert an indwelling urinary cath b. request a rx for an antipyretic med c. obtain a cutlure sample of the client's blood d. request a rx for an antihistamine med e. obtain a rx for a diuretic med f. begin infusing 0.9% sodium chloride solution g. stop the client's blood transfusion

B, C, F, G

A nurse in an ED is assessing a client who is having suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute IM? select all that apply a. orthopnea b. headache c. nausea d. tachycardia e. diaphoresis

C, D, E

A nurse is caring for a client who has anemia select the 4 findings that require immediate follow up a. iv site b. o2 sat c. temp d. back pain e. breath sounds f. urine color g. BP

C, D, F, G

A nurse is planning care for adolescent client Which of the following actions should the nurse plan to take? Select all that apply a. apply cold compresses to joint b. admin IV fluid c. restrict fluid intake to 1400 ml/day d. provide o2 at 6L/min via nasal cannula e. perform passive ROM exercises f. obtain consent for blood transfusion g. encourage bedrest h. admin meperidine IV

E, B, F, G

Client in ED with substernal chest pain that comes and goes. Pain occurring for last 8 hr. Pain radiates down the L arm. intermittent nausea appears pale and slightly diaphoretic. current pain 07/10 For each potential rx, indicated whether indicated, nonessential, or contraindicated

ECG: anticipated fhx: non essential o2: anticipated IV furosemide: contraindicated intubation: contraindicated vascular access: anticipated

Client reports mowing lawn and began to feel bad. experienced pain in L arm that radiated to the neck and back and then began to feel pain across their chest. client chewed one baby aspirin and had neighbor bring to ED pain 07/10 and feeling of tightness in chest What condition most likely experiencing, 2 parameters to monitor, and 2 actions to take

Potential condition: MI actions to take: nitro infusion, prepare for PCI 2 parameters to monitor: cardiac enzymes, dysrhythmias

Client arrives to ED and reports fluttering and racing heartbeat. Also reports dizziness and SOB. Placed on tele....rhythm irregular, tachy, and unclear P waves Select condition client is most likely experiencing and 2 actions nurse should address and 2 parameters should monitor

Potential condition: atrial fib actions to take: 12 lead ECG, administer anticoagulant parameters to monitor: PTT/INR, manifestations of stroke

Complete the diagram from the choices below to specify what condition the client is most likely experiencing, 2 actions, 2 parameters should monitor EX: 84 yr old male client who is being admitted from a provider's office

Potential condition: heart failure Actions to take: elevate the head of the bed, encourage intake of low sodium diet Parameters to monitor: urinary output, blood pressure

For each of the following findings in the client's med record, click to specify if they are consistent with angina or MI. Each finding may support more than one disease process

Provider consult: angina and MI nitro therapy: angina initial manifestations: angina and MI 12 lead EKG: angina and MI treadmill stress test: angina

A nurse is caring for a client who is receiving a blood transfusion Complete the following sentence by using the lists of options

The client is likely experiencing TACO (transfusion-associated circulatory overload) as evidence by the client's respiratory assessment

A nurse is caring for a client who was admitted for pain between their shoulder blades

The nurse has completed the client's admission hx. The client is most likely suffering from angina as evidenced by the client's serum lipids

A nurse is caring for a client who reports fatigue and had a syncopal episode at home. Complete the following sentence by using the list of options

The nurse should first address the client's oxygen saturation followed by the client's hypotension

A nurse is reviewing data for four children. Which of the following children should the nurse assess first? a. 10 yr old who has sickle cell anemia who reports severe chest pain b. 7 yr old who has diabetes insipidus and a urine specific gravity of 1.016 c. 1 yr old who has roseola and temp of 102.2 d. 4 yr old child who has asthma and PCO2 of 37

a. 10 yr old who has sickle cell anemia who reports severe chest pain

A nurse is preparing to admin 2 units of PRBCs to an older client. Which of the following actions should the nurse take? a. admin each unit over 3 hr b. use an 18 g needle to obtain venous access c. use blood that is less than a month old d. obtain the client's VS q30 min throughout the transfusion

a. admin each unit over 3 hr

A nurse is preparing fot administer blood to a client. The unit of blood on hand is type O neg, and the client has a type A pos blood. Which of the following actions should the nurse take? a. admin the blood as ordered b. contact the provider for further orders c. notify the blood bank d. complete an incident report

a. admin the blood as ordered

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B and the client has type AB blood. Which of the following actions should the nurse take? a. admin the blood as ordered b. contact the provider for further orders c. notify the blood bank of the discrepancy d. complete an incident report

a. admin the blood as ordered

A nurse is providing teaching about IDA to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing IDA? a. avoid diet that consists primarily of milk b. admin fat soluble vitamins daily c. include fluoridated water in the toddler's diet d. limit intake of high protein foods

a. avoid diet that consists primarily of milk

A nurse is assessing a client who is receiving a unit of PRBCs. Which of the following findings is a manifestation of an acute hemolytic transfusion reaction? a. flank pain b. wheezing c. hives d. distended neck veins

a. flank pain

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? a. the P wave falls before the QRS complex b. the T wave is in the inverted position c. the P-R interval measures 0.2 seconds d. the QRS duration is 0.20 sec

a. the P wave falls before the QRS complex

A nurse at a provider's office receives a phone call from a client who reports nausea and unrelieved chest pain after taking nitro tab 5 min ago. Which of the following is an appropriate response by the nurse? a. tell the client to take an antacid b. instruct the client to call 911 c. tell the client to take another nitro tab in 15 mins d. advise the cleint to come to office

b. instruct the client to call 911

A nurse is caring for a client who is prescribed warfarin for an artificial heart valve. Which of the following lab values should the nurse monitor for a therapeutic effect of warfarin? a. hgb b. PT c. bleeding time d. aPTT

b. PT

A nurse is reviewing the medical record of a client who has HTN and a new rx for metoprolol. Which of the following findings should the nurse investigate further? a. diet controlled type 2 DM b. a hx of L sided HF c. concurrent rx for tadalafil d. recently treated bilateral pneumonia

b. a hx of L sided HF

A nurse is caring for four clients. After admin morning meds, she realizes that the nifedipine prescribed for one client was inadvertently admin to another client. Which of the following actions should the nurse take first? a. notify the client's provider b. check the client's vital signs c. fill out an occurrence form d. admin the med to the correct client

b. check the client's vital signs

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion? a. hypothermia b. chills c. nystagmus d. bradycardia

b. chills

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these fidnings indicate which of the following transfusion reactions? a. febrile b. hemolytic c. allergic d. bacterial

b. hemolytic

A client is teaching a client who has a new rx for HCTZ for management of HTN. Which of the following instructions should the nurse include? a. take this medication before bedtime b. monitor for leg cramps c. avoid grapefruit juice d. reduce intake of potassium rich foods

b. monitor for leg cramps

A nurse is providing teaching to a client who has a FHX of HTN. The nurse should inform the client that his BP of 124/84 places him in which of the following categories? a. within the expected reference range b. prehypertension c. stg 1 htn d. stg 2 htn

b. prehypertension

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. stop the infusion

A nurse is teaching a clinet who has a new rx for clopidogrel. Which of the followign instructions should the nurse include? a. take this medication with food b. you might have to stop taking this medication 5 days before any planned surgeries c. take this medication 3x daily d. expect to have black colored stools while taking this medication

b. you might have to stop taking this medication 5 days before any planned surgeries

A client who has a hx of MI is prescribed aspirin 325mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? a. analgesic b. anti inflammatory c. antiplatelet aggregate d. antipyretic

c. antiplatelet aggregate

A nurse is caring for a client who has Afib and is receiving heparin. Which of the following findings is the nurse's priority? a. client's ECG tracing shoes irregular HR without P waves b. client has an aPTT of 80 sec c. client experiences sudden weakness of one arm and leg d. client's urine output is cloudy and odorous

c. client experiences sudden weakness of one arm and leg

A nurse is preparing to administer medications to four clients. The nurse shuld admin medications to which of the following clients first? a. client who has pneumonia, WBC 11,500 and prescribed piperacillin b. client who has anemia, hgb 11 g/dl and prescribed epoetin alfa c. client who has renal failure, potass 5.8, prescribed polystyrene sulfonate d. client who is post CABG and has total cholestrol 318 and prescribed atorvastatin

c. client who has renal failure, potass 5.8, prescribed polystyrene sulfonate

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first? a. client who has pneumonia, WBC count of 11,500 and is prescribed piperacillin b. client who has anemia, hgb of 11 g/dl and is prescribed eopetin alfa c. client who has renal failure, serum potass 5.8 and is prescribed sodium polystyrene sulfonate d. clienw ho is post CABG, has a total cholesterol of 318 and is prescribed atorvastatin

c. client who has renal failure, serum potass 5.8 and is prescribed sodium polystyrene sulfonate

A nurse is teaching a client who takes aspirin daily for CAD about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin? a. cranberry juice b. aloe vera c. feverfew d. flaxseed

c. feverfew

A nurse is monitoring a client who is receiving a unit of PRBCs following surgery. Which of the following assessments is an indication the cleint might be experiencing a hemolytic reaction? a. flushing b. dyspnea c. hypotension d. vomiting

c. hypotension

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan? a. discourage a high level of fluid intake b. apply cold compress to painful, swollen joints c. observe for indications of hypokalemia d. admin meperidine every 4 hr for pain

c. observe for indications of hypokalemia

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing an MI? a. check the client's BP b. auscultate heart tones c. perform a 12 lead ECG d. determine if pain radiates to the L arm

c. perform a 12 lead ECG

A nurse is caring for a client who is receiving heparin by continuous IV. Which of the following medications should the nurse plan to administer in the event of an overdose? a. iron b. glucagon c. protamine d. vitamin K

c. protamine

A nurse is assessing a client before admin a unit of PRBCs. 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. temp d. hgb level

c. temp

A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a MI. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? a. troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissues b. troponin is a lipid whose levels reflect the risk for CAD c. troponin is a heart muscle protine that appears in the bloodstream when there is damage to the heart d. troponin is a protein that helps transport oxygen throughout the body

c. troponin is a heart muscle protine that appears in the bloodstream when there is damage to the heart

A nurse is instructing the motherof a toddler who has iron deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following foods should the nurse recommend? a. skim milk b. bananas c. tuna fish d. cucumbers

c. tuna fish

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factos should the nurse include? a. hx of smoking b. obesity c. hx of htn d. genetics

d. genetics

A nurse is providing teaching to a client who has a new rx for lisinopril. Which of the following statements by the nurse indicates an understanding of the teaching? a. i should increase my intake of potassium rich foods b. i should expect to have facial swelling when taking this medication c. i should take this medication with food d. i should repoert a cough to my provider

d. i should repoert a cough to my provider

A nurse is providing teaching to a client who has angina pectoris and a new rx for nitro sublingual tabs. Which of the following statements by the client indicates an understanding of the teaching? a. ill dial 911 if i still have pain after taking 3 nitro tabs 5 mins apart b. ill dial 911 if i still have pain after taking 4 nitro tabs over a 20 min period c. ill dial 911 when i have pain and then take the nitro tabs d. ill dial 911 if 1 nitro tab does not relieve my pain and then take up to 2 more tablets 5 min apart while waiting

d. ill dial 911 if 1 nitro tab does not relieve my pain and then take up to 2 more tablets 5 min apart while waiting

A nurse is caring for a clinet who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first? a. return the unit of blood to the blood bank b. infuse 0.9% sodium chloride c. obtain a blood sample from the client d. stop the transfusion

d. stop the transfusion

A nurse is assessing a client who is receiving a unit of PRBCs. Which of the following findings is a manifestations of an allergic transfusion reaction? a. elevated BP b. distended neck veins c. flank pain d. wheezing

d. wheezing

A nurse is caring for a client in the outpatient cardio office. Which of the following findings indicates that the client's condition has improved or not changed since their 2 week f/u appt?

dyspnea: unchanged O2sat: unchanged jugular venous distention: improved lung sounds: improved serum potassium: improved weight: improved

Client brought to ED for pain in L arm. hx of sickle cell dx at age 4. client has rx for oral morphine and took one dose last evening and this morning. reports 09/10 for pain specify if anticipated, nonessential, or contraindicated

ketorolac iv: anticipated IVF maintenance: anticipated ambulate in hallway: contraindicated meperidine IV: contraindicated ice packs: contraindicated

For each finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, or leukemia. Each finding may support more than 1 disease process ankle ulcer jaundice resp status joint pain HR at 1000

sickle cell: ankle ulcer, resp status, joint pain, HR, jaundice IDA: resp status, HR leukemia: resp status, joint pain, HR

24 yr old client reports throbbing pain, swelling, discoloration, warmth in R calf for 3 days drag the words from the choices believe to fill in each blank in the following sentence

the client is exhibiting clinical manifestations of DVT and pulmonary embolism