NUR 307 Ati Practice Questions

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates further teaching?

"I may eat 10 ounces of lean protein each day" RATIONALE: Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care?

-Have the client remain in bed up to 6 hr is correct -Keep the client's hip and leg extended is correct. -Check peripheral pulses in the affected extremity is correct

Suctioning a tracheostomy step by step:

1. adjust the suction 2. don sterile gloves. 3. check the function of the suction catheter by suctioning a small amount of solution into the tubing, 4. hyperoxygenate the client using a manual resuscitation bag valve mask connected to oxygen. 5. insert the suction catheter without suction and then apply suction for no more than 10 seconds while rotating the catheter. 6. assess for clearance of secretions.

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching?

Apply the transdermal patch in the morning RATIONALE: The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

A nurse is caring for a client who is experiencing status asthmaticus. What nursing intervention should the nurse take?

Administer a SABA to relive bronchoconstriction and improve ventilation

A nurse in an emergency apartment is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?

Albuterol RATIONALE: Albuterol is considered a "rescue" medication due to its rapid onset of action. Asthma is a chronic inflammatory disorder of the airways. Asthmatic episodes are associated with airflow limitation or reversible obstruction. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma by promoting bronchodilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or as a parenteral preparation. The inhaled medication has a more rapid onset of action than the oral form and also reduces the risk for the adverse effects of irritability, tremor, nervousness, and insomnia.

A home health care nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Assess the client's respiratory status RATIONALE: The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

A nurse is caring for a client with hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that is medication is contraindicated in clients who have a history of what condition?

Asthma RATIONALE: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation

The nurse is a caring for a client with heart failure and a history of asthma. The nurse reviews the providers orders and recognizes that clarification is needed for what medication?

Carvediol RATIONALE: Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.

A nurse is caring for a client who has a disposable three chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Continuous bubbling in the water-seal chamber RATIONALE: excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system)

A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that what herbal supplement may interact adversely with aspirin?

Feverfew RATIONALE: The nurse should instruct the client to avoid taking feverfew with aspirin because it suppresses platelet aggregation and places the client at risk for bleeding when taken with aspirin.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the manifestations should the nurse expect?

agitation RATIONALE: The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse is assessing a client with COPD. The nurse should expect the client's chest to be with of the following shapes?

barrel chest RATIONALE: Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

development of subcutaneous emphysema RATIONALE: subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.

A nurse is caring for a client who has 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?

encouraging the client to drink 2 to 3 of water daily RATIONALE: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

Metformin RATIONALE: Metformin interacts with contrast dye and can cause acute kidney damage.

A nurse is caring for a client 4hr following a cardiac catheterization. Which of the following actions should the nurse take?

Have the client lie flat in bed RATIONALE: The nurse should have the client on lie flat in bed. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

I will follow a daily diet high in calories and protein RATIONALE: Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals

A nurse is teaching a client who has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching?

I will take bronchodilators after meals RATIONALE: Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.

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?

Instruct the client to use pursed lip breathing RATIONALE: pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Radial pulse in the left arm RATIONALE: Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombophlebitis and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse.

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?

Rinse the mouth after administration RATIONALE: Use of glucocorticoids by metered dose inhaler can allow a fungal overgrowth in the mouth. Rinsing the mouth after administration can lessen the likelihood of this complication.

A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazde. Which of the following instructions should the nurse provide?

Take the medication early in the day RATIONALE: The nurse should instruct the client to take hydrochlorothiazide early in the day to avoid nocturia (frequent urination at night)

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

keep the drainage system below the level of the client's chest of all times RATIONALE: During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

obstructive sleep apnea (OSA) RATIONALE: The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicatior of central cyanosis?

oral mucosa RATIONALE: According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is caring for client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?

secure new tracheostomy ties before removing old ones RATIONALE: Tube dislodgement and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying new ties, the nurse can secure the tube and prevent dislodgement.

A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release tablets. Which of the following instructions should the nurse include?

swallow the capsules whole RATIONALE: The client should swallow the capsules whole and not chew or crush them or place them under the tongue.