Medical Surgical Exam 3: ATI practice questions

A nurse is caring for a client who experienced a TBI. Which finding indicates ICP?

Dilated pupils

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is reviewing the morning laboratory results of an infant who is receiving digoxin and furosemide for the treatment of HF. Which of the following findings should the nurse report to the provider?

Potassium 3.2

A nurse is caring for a client who is experiencing cycloplegia following the administration of atropine eye drops during an eye examination. Which of the following findings should the nurse expect as a result of cycloplegia?

Blurred vision

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps?

1. palpate the BP and inflate the cuff above the SBP 2. deflate the cuff slowly and listen for the first audible sounds. 3. identify the first BP sounds audible on expiration and then on inspiration 4. subtract the inspiratory pressure from the expiratory pressure 5. Inspect for JVD distension and notify HCP

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the client's affected extremity?

Ankle swelling Brown pigmentation Cellulitis

A nurse is assisting a client who has dysphagia with eating meals. Which action should the nurse take?

Ask the cleint to think of a food that produces salivation

A nurse is caring for a client and realizes after administering the 0900 medication that she administered digoxin 0.25 mg PO to the client instead of the prescribed digoxin 0.125 mg PO. Which of the following actions should the nurse take first?

Assess the clients apical pulse

A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take?

Auscultate blood pressure for pulsus paradoxus Explanation: The client who has CT will have pulsus paradoxus when the SBP is at least 10 mm higher on expiration than on inspiration.

A nurse in a rehab center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which should the nurse expect?

Difficulty with speech

A nurse is performing a neuro check for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement?

Dysphagia

A nurse is providing teaching to a client with a new diagnosis of HF who has a prescription for furosemide. Which of the following statements should the nurse include in the teaching?

Eat foods that are high in K+

A nurse is assessing a client who has ICP and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication?

Increased urine output

A nurse is caring for a client who has a left intracranial hemorrhage from a stroke. Which of the following findings should the nurse expect?

Right-sides hemiplegia

A nurse is caring for a client who has a closed traumatic brain injury and is experiancing ICP. This increase in ICP is due to?

Rigid skull containing cranial contents

A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client?

The client is unable to understand words or sentence she hears.

A nurse is providing discharge teaching to a client who has angina pectoris and a new prescription for verapamil. The client tells the nurse, "My brother takes verapamil for high blood pressure. Do you think the provider made a mistake?" Which of the following responses should the nurse make?

Verapamil is used to treat both high blood pressure and angina.

A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity?

Visual disturbances

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVC). Which of the following QRS changes should the nurse expect to see on the client's ECG?

Much greater amplitude than the usual QRS complexes

A nurse is reviewing lab values of a client who is receiving IV heparin infusion and has a aPTT of 90 se. What should the nurse do?

Reduce infusion rate.

A nurse is caring for a client who has a TBI and assumes decerebrate posture in response to noxious stimuli. Which would the nurse anticipate?

The client rigidly extends his arms.

A nurse is assessing a client with a closed head injury who has received mannitol for ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

The clients osmolarity is 310 mOsm/L

Recent head injury. Which of the following findings should the nurse recognize as a manifestation of ICP?

Widening pulse pressure Bradycardia

A nurse is assisting a client who has dysphagia at mealtimes. Which os the following actions should the nurse take?

Advise the client to tuck his chin downward

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the clients brain?

Frontal

A nurse is preparing to administer digoxin to a client. Which of the following should the nurse identify as a contraindication to the client receiving this medication?

HR 51 BPM

A nurse is caring for a client who has heart failure and is prescribed dobutamine hydrochloride by continuous IV infusion. The nurse should identify that which of the following is the therapeutic effect of this medication?

Improves cardiac output

A nurse is planning care for a client who has aphasia following a stroke. Which action should the nurse take?

Offer pictures for the client to point to as an alternative form of communication.

A nurse is caring for a client who had a CVA. Which should the nurse do at meal time?

Offer the client tart or sour foods first

A nurse is assessing an older adult client who has right-sided heart failure. Which of the following findings is the nurse's priority?

The client's weight has increased by 2 pounds in 24 hours

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect?

Elevated ST segments

A nurse is providing discharge teaching to a client who has heart failure and a prescription for digoxin 0.125 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates and understanding of teaching?

I will eat fruits and veggies that have a high potassium content every day

A nurse is caring for a client who has CHF. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first?

Check apical pulse

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching?

I will notify my doctor before I have dental procedures

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T-wave. Which of the following lab results should the nurse anticipate as the cause of the ECG change?

Potassium of 2.8

A nurse is planning care for a client who has aphasia following a stroke. Which action should the nurse take?

Present a single idea in a sentence.