Exam 1 (ATI Review)
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following info should the nurse include? (D)
a) most clients exaggerate their level of pain b) pain must have in identifiable source to justify the use o opioids c) objective data are essential in assessing pain d) pain is whatever the client says it is
A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer? (C)
a) naloxone b) morphine c) flumazenil d) atropine
A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? (C)
a) phamton limb pain b) mixed pain c) breakthrough pain d) neuropathic pain
A nurse is assessing a client's lab values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply) (CDE)
a) potassium 3.9 mEq/L b) sodium 145 mEq/L c) creatinine 2.8 mg/dL d) blood glucose 235 mg/dL e) WBC 17,850/mm
A nurse is caring for a client who has suspected viral skin lesion. Which of the following lab findings should the nurse expect to review to confirm this dx? (C)
a) potassium hydroxide (KOH) b) diascopy c) Tzanck smear report d) biopsy
A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse to perform this test? (C)
a) apply a blood pressure cuff to the client's arm b) place the stethoscope bell over the client's carotid artery c) tap lightly on the client's cheek d) ask the client to lower their chin to their chest
A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? (B)
a) apply heat to the puncture site b) place the client in a supine position c) turn the client every 1 hr d) ambulante the client within the first hour postprocedure
A nurse is caring for a client who reports nausea and vomiting 2 days postop following hysterectomy. Which of the following actions should the nurse perform first? (A)
a) assess bowel sounds b) administer antiemetic medication c) restart prescribed IV fluids d) insert a prescribed nasogastric tube
A nurse is planning care or a client is postop following an arthroscopy of the knee. Which of the following actions should the nurse take? (Select all that apply) (ACDE)
a) assess color and temp of extremity b) apply warm compresses to incision sites c) place pillows under the extremity d) administer analgesic medication e) assess pulse and sensation in the foot
A nurse is planning care for aa client who will undergo an electromyography (EMG). Which of the following actions should the nurse include? (Select all that apply) (ACD)
a) assess for bruising b) administer aspirin prior to the procedure c) determine whether the client takes a muscle relaxant d) instruct the client to flex muscles during needle insertion e) expect swelling, redness, and tenderness at the insertion site
A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? (A)
a) assess oxygen saturation b) measure oxygen saturation c) palpate pulse rate d) check temperature
A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? (A)
a) ketorolac b) ketamine c) meperidine d) methadone
A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect? (D)
a) moist skin b) distended neck veins c) increased urinary output d) tachycardia
A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? (B)
a) monitor blood creatinine levels b) provide airway support c) turn the client to the right side d) administer a diuretic
A nurse is completing preop teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (Select all that apply) (BCE)
a) "Avoid damage or moisture to the cast on your arm" b) " Inspect your incision daily for indications of infection" c) "Apply ice packs to the area for the first 24 hours" d) "Keep your arm in a dependent position" e) "Perform isometric exercises"
A nurse is providing discharged instructions to a client who had a skin biopsy with sutures. The nurse should identify that which of the following client statements indicates that the teaching has been effective? (C)
a) "I can expect redness around the site for 5 to 7 days" b) "I will most likely have a fever for the first few days" c) "I should apply an antibiotic ointment to the area" d) "I will make a return appointment in 3 days for removal o my sutures"
A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply) (ABCE)
a) "I will clean the pins more often if drainage from te pins increases" b) "I will use a separate cotton swab for each pin" c) "I will report loosening of the pins to my doctor" d) "I will report increased redness at the pin sites"
A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply) (ABCE)
a) remove throw rugs in walkways b) use rx assistive devices c) remove clutter from the environment d) wear soft-bottomed shoes e) maintain lighting of doorway areas
A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply) (CE)
a) scrape the site with a wooden tongue depressor b) use a razor to cut the scabbed area to obtain fluid from the lesion c) use a cotton-tipped application to obtain fluid from the lesion d) place specimen in a potassium hydroxide (KOH) solution tube e) place specimen tube on ice after obtaining sample
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? (C)
a) "I'll wait to use the device until it's absolutely necessary" b) "I'll be careful about pushing the button so I don't get an overdose" c) "I should tell the nurse if the pain doesn't stop after I use this device" d) "I will ask for my son to push the dose button when I am sleeping"
A nurse is providing teaching to a client about a new rx for clotrimazole topical cream. Which of the following statements should the nurse include? (C)
a) "It reduces the discomfort of a herpetic infection but does not cure the infection" b) "This is a cream to treat a bacterial infection" c) "Apply the topical medication for up to 2 weeks after the fungal lesions are gone" d) "Apply the cream to lesions while they are moist"
A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply) (ABD)
a) "Take your heart medication with a sip of water before surgery" b) "Splint the abdominal incision with a pillow when coughing and deep breathing" c) "Bed rest is recommended for the first 48 hours" d) "Anti-embolism stockings are applied before surgery" e) "You can eat solid foods up to 4 hours before surgery"
A nurse is teaching a client who has a new diagnosis of RA. Which of the following statements should the nurse include in the teaching? (A)
a) "You can experience morning stiffness when you get out of bed" b) "You can experience abdominal pain" c) "You can experience weight gain" d) "You can experience low blood sugar"
A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include? (D)
a) "You will receive an injection of a radioactive isotope when the scanning procedure begins" b) "You will be inside a tube-like structure during the procedure" c) " You will need to take radioactive precautions with your urine for 24 hours after the procedure" d) " You will have to urinate just before the procedure"
A nurse is caring for a client who has blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? (A)
a) ECG changes b) constipation c) polyuria d) paresthesia
A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply) (ACDE)
a) a 40-year-old client who has been taking prednisone for 4 months b) a 30-year-old client who jogs 3 miles daily c) a 45-year-old client who takes phenytoin for seizures d) a 65-year-old client who has a sedentary lifestyle e) a 70-year-old client who has smoked for 50 years
A nurse is reviewing the medical records of several client's in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply) (ABCD)
a) a client who has a WBC of 22,500/uL b) a client who uses an insulin pump c) a client who takes warfarin daily d) a client who has heart failure e) a client who has a BMI of 26
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? (D)
a) age 78 y/o b) hx of cancer c) previous joint replacement d) bronchitis 2 weeks ago
A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? (A)
a) altered mental status b) reduced bowel sounds c) swelling of the toes distal to the injury d) pain with passive movement of the foot distal to the injury
A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following info should the nurse include? (A)
a) antibiotic therapy should continue for 3 months b) relief of pain indicates the infection is eradicated c) airborne precautions are used during wound care d) expect paresthesia distal to the wound
A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? (C)
a) bathe daily with moisturizing soap b) apply antibacterial topical medication to the crusted exudate c) apply warm compresses to the affected area d) cover affected area with snug-fitting clothing
A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply) (ABD)
a) check continuous passive motion device settings b) palpate dorsal pedal pulses c) place a pillow behind the knee d) elevate heels off bed e) apply heat therapy to incision
A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply) (ACE)
a) clean the incision daily with soap and water b) turn the toes inward when sitting or lying c) sit in a straight-backed armchair d) bend at the waist when putting on socks e) use a raised toilet seat
A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? (D)
a) compare and contrast the pheripheral pulses b) apply a warm blanket c) assess dressings d) place the client in a lateral position
A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? (C)
a) decrease the client's fluid intake b) apply pressure to the puncture site c) place the head of the bed flat d) instruct the client to lie prone
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) (ABDE)
a) decreased skin turgor b) concentrated urine c) bradychardia d) low-grade fever e) tachypnea
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? (A)
a) diabetic ketoacidosis b) heart failure c) Cushing's syndrome d) thyroidectomy
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect? (Select all that apply) (ABDE)
a) dyspnea b) edema c) bradychardia d) hypertension e) weakness
A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply) (ADE)
a) encourage a complete autologous blood donation b) it in a low reclining chair c) instruct the client to roll onto the operative hip d) use an abductor pillow when turning the client e) perform isometric exercises
A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? (D)
a) encourage the client to void after preoperative medication administration b) administer antibiotics 2 hr prior to surgical incision c) remove hair using a manual razor d) remove nail polish on fingers and toes
A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following actions should the nurse perform first? (ABCE)
a) encourage use of the incentive spirometer every 2 hr b) instruct the client to splint the incision when coughing and deep breathing c) reposition the client every 2 hr d) administer antibiotic therapy e) assist with early ambulation
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply) (CDE)
a) explain to the client the purpose of having the procedure b) inform the client of risks to having the procedure c) ensure the client understands info about the procedure d) witness the client signing the informed consent form e) determine if the client is capable of understanding the reason for the procedure
A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (Select all that apply) (BCDE)
a) history of consuming one glass of wine daily b) loss in height of 2 in (5.1 cm) c) body mass index (BMI) of 18 d) kyphotic curve of upper thoracic spine e) history of lactose intolerance
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? (B)
a) hypercalcemia b) hyponatremia c) hyperphosphatemia d) hyperkalemia
A nurse is caring for a client who is scheduled for an explanatory laparotomy. The client's temperature is 39 C (102.2 F) orally. Which of the following actions should the nurse take? (A)
a) inform the surgeon of the elevated temperature b) transfer the client to the preoperative room c) apply ice packs to the groin d) encourage the client to increase intake of clear liquids
A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all that apply) (ABCE)
a) infused iced IV fluids b) provide 100% oxygen c) place a cooling blanket on the client d) treat the complications while the surgeon continues surgery e) administer IV dantrolene
A nurse is caring for a client in a long-term care facility who has become weak, confused, and experienced dizziness when standing. The client's temperature is 38.3 C (100.9 F), pulse 92/min, respiration 20/min, and blood pressure 108/60 mm Hg. Which of the following actions should the nurse take? (D)
a) initiate fluid restrictions to limit intake b) check for peripheral edema c) encourage the client to ambulate to promote oxygenation d) monitor for orthostatic hypotension
A nurse is assessing a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply) (ACDE)
a) intense pain when the client's left foot is passively moved b) capillary refill of 3 sec on the client's left toes c) hard, swollen muscle of the client's foot d) burning and tingling of the client's left foot e) client report of minimal pain relief following a second dose of opioid medication
A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? (Select all that apply) (ABE)
a) recent influenza b) decreased range of motion c) hypersalivation d) increased blood pressure e) pain at rest
A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? (B)
a) skeletal traction b) buck's traction c) halo traction d) bryant's traction
A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply) (BCDE)
a) skin reddened over the joint b) pain when nearing weight c) joint crepitus d) swelling of the affected joint e) limited joint motion
A nurse is educating clients at a health fair about dual-energy x-ray absorprtiometry (DXA) scans. Which of the following information should the nurse include? (Select all that apply) (BDE)
a) the test require the use of contrast material b) the hip and spine are the usual areas the device scans c) the scan detects osteoarthritis d) bone pain can indicate a need for a scan e) females should have a baseline scan during their 40s
A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level of 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these lab findings? (A)
a) three tap water edemas b) 0.9% sodium chloride solution IV at 50 mL/hr c) 5% dextrose with 0.45% sodium chloride solution with 20 mEq of K IV at 80 mL/hr d) antibiotic therapy
A nurse is caring for a client who has RA. Which of the following laboratory tests are used to dx this disease? (Select all that apply) (BDE)
a) urinalysis b) erythrocyte sedimentation rate (ESR) c) BUN d) antinuclear antibody (ANA) titer e) WBC count
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply) (CDE)
a) urinary incontinence b) diarrhea c) bradypnea d) orthostatic hypotension e) nausea
A nurse is caring for a client who manifests indicaitons of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply) (ABCD)
a) urine output less than 25 mL/hr b) hematocrit 53% c) BUN 24 mg/dL d) Tenting of skin over the sternum e) apical pulse rate 62/min
A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? (B)
a) white bread b) kale c) apples d) brown rice