ATI B

a nurse is obtaining the health history of a client who has abdominal aortic aneurysm. Which of the following findings should the nurse expect?

Bruit heard over the middle upper abdomen

a home health nurse is providing teaching to a client who has a stage 1 pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour

a nurse is reviewing the lab results of a client who has cirrhosis? Which of the following lab values should the nurse expect?

Elevated bilirubin level

a nurse is providing teaching to a client who has ESKD and is waiting for a kidney transplant. Which of the following information should the nurse provide?

Hemodialysis is sometimes needed following surgery

a nurse admits a client who has anorexia, low grade fever, night sweats, and productive cough. which of the following actions should the nurse take first?

Initiate airborne precautions

a nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching?

Take additional pairs of shoes

a nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicated an adverse effect of the medication?

Urinary retention

a nurse is caring for a client who has a stage 3 pressure ulcer. which of the following findings contributes to delayed wound healing?

Urine output of 25 mL/hr

a nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use 30 mL syringe

a home health nurse is assigned to a client who has recently discharged from a rehab center after experiencing a right-hemisperic CVA. Which of the following neurologic deficits should the nurse expect to find when assessing the client?

Visual spatial deficits Left hemianopsia one-sided neglect

a nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect? a. muscle atrophy b. ataxia c. weight loss d. hypotension

a. muscle atrophy

a nurse is assessing a client who has diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain?

alternate application of heat and cold to the affected joints

a nurse is caring for a client who has pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

bubbling in the water seal chamber has ceased

a nurse is assessing heart sounds of the client who reports substernal precordial pain.

pericardial friction rub

a nurse is assessing a client following the admin of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?

respiratory paralysis

a nurse is assessing a client following IV urography. Which of the following findings is the priority?

swollen lips

a nurse is caring for a newly admitted client who has gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take.

1. admin oxygen 2. initiate IV therapy 3. NG tube 4. admin ranitidine

a nurse is preparing to admin amikacin 500mg by intermittent IV bolus to a client. Available is amikacin 500 mg in dextrose 5% in water 200 mL to infuse over 30 min. The nurse shuol set the IV pump to deliver how many mL/hr?

400 mL/hr

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understand the teaching? a. I will wash the ink markings off the radiations area after each treatment b. I will use my hands rather than a washcloth to clean the radiation area c. I will be able to be out in the sun 1 month after my radiation treatment are over d. I will use a heating pad on my neck if it becomes sore during the radiation therapy

B i will use my hands rather than a washcloth to clean the radiation area

a nurse is caring fro a client who is receiving TPN and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? a. check the clients blood glucose according to facility mealtimes b. contact the primary care provider to clarify the prescription c. request for meal to be provided for the client d. hold the prescription until the client is no longer NPO

B. contact the primary care provider to clarify the prescription

A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider? a. Rhinitis b. crackles heard on auscultation c. increased urinary output d. decreased deep tendon reflexes

B. crackles heard on auscultation

a nurse is caring for a client who has amymtrophic lateral sclerosis (ALS) and is being admitted tot he hospital with pneumonia. Which of the following assessment findings is the nurses priority? a. temp 38.4 (101.1) b. increased respiratory secretions c. fluid intake of 200 mL in the prior 8 hr d. limited range of motion

B. increased respiratory secretions

A nurse is caring for a client who is receiving a blood transfusion. the client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? a. administer an antihistamine b. slow the infusion rate. c. give the client a corticosteroid d. elevate the clients lower extremities

B. slow the infusion rate

a nurse on a med surg unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. which of the following client information should indicate to the nurse that the client requires a revision of the IV therapy prescription?

BUN

a nurse is caring for a client who has DKA. which of the following lab findings should the nurse expect?

BUN 32 mg/dL

A nurse is assessing a client who had extracorporeal shock wave lithotrispy 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

a nurse is caring for a client who has cirrhosis of the liver with esophageal varices. Which of the following activities should the nurse instruct the client to avoid?

Strainging to have bowel movement

a nurse is caring fro a client who has had cerebraovascular accident. Which of the following findings indicated that the client has homonymous hemianopsia?

The client has to turn her head to see the entire visual field

a nurse in an ICu is assessing a client who has a TBI. which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia

a nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

C- a smooth, red tongue

a nurse is reviewing the lab results of a client who has AIDS and is taking amphotericin B for fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication a. potassium 4.8 b. magnesium 1.7 C. BUN 34 D. hematocrit 45%

C. BUN 34

a nurse is providing teaching to a client who take ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? a. "ginkg biloba relieves nausea for people who hace vertigo." b."taking ginkgo biloba will help relieve your joint pain. c. ginkgo biloba can cause an increased risk for bleeding d. taking ginkgo biloba decreased the risk of migraine headahce

C. risk for bleeding

a nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium

a nurse is reviewing the lab findings of a client who developed chest pain 6 hr ago. the nurse should identify which of the following findings as an indication of a myocardial infarction?

Troponin I 8 ng/mL

an older adult client is brought to an ED by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity is 1.045

a nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse

a nurse is in an ED is caring for a client who reports chest pain of 8 on a pain scale of 0-10. whihc of the following actions should the nurse take first

admin morphine

a nurse is caring for a client 1 hr following a cardiac cath. the nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate int he affected extremity. Which of the following interventions is the nurses priority?

apply firm pressure to the insertion site

a nurse is assessing an older adults client who has heart failure and takes digoxin. which of the following findings should the nurse recognize as an indications of digoxin toxicity?

bradycardia

a nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understand of the teaching? a. this measures how much blood my heart is pumping b. this identifies if i have a defective heart valve c. this identifies if the pacemaker cells of my heart are working properly d. this measures the blood circulating to my heart muscle

c. this identifies if the pacemaker cells of my heart are working properly

a nurse is caring for a client who has pancreatitis. the nurse should expect which of the following laboratory resilts to be below the expected reference range?

calcium

a nurse is caring for a client who is undergoing renal dialysis to treat ESKD. The client reports muscle cramps and tingling sensation in his hands. which of the following medication should the nurse plan to admin.

calcium carbonate

a nurse is reviewing the health record of a client who is scheduled for allergy skin testing the nurse should postpone the testing and report to the provider which of the following findings?

current medications

A nurse is developing a teaching plan for a client who has gout. which of the following recommendations should the nurse include?

decreased intake of purine meats

a nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?

decreased viral load

a nurse is assessing a clients hydration status. which of the following indicates fluid volume overload?

distended neck veins

a nurse is providing education to a client who has TB and his family. Which of the following information should the nurse include in the teaching?

family members in the household should undergo TB testing

a nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understand the teaching?

grilled chicken breast

A nurse is assessing a clientt who is postop following a transurethral resection of the prostate (TURP) and notes clots in the clients indwelling urinary catheter and decrease in urinary output. Which of the following actions should the nurse take?

irrigate the indwelling urinary catheter

a nurse in an emergency department is assessing a client who has detached retina. Which of the following should the nurse expect the client to report?

its like a curtain closed over my eye

a client who has diagnosis of C. diff is placed on contact percautinos. Which of the following actions should the nurse take?

leave a stethoscope in the room for blood pressure monitoring

a nurse is caring fro a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

loosen restrictive clothing

a nurse is admin packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

low back pain and apprehension

a nurse is providing teaching to a client who has severe form of stage 2 lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

my joints ache because I have Lyme disease

a nurse is caring for a client who has viral pneumonia. The clients pulse oximeter readings have fluctuated between 79% and 88% for the last 30min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

nonrebreather mask

a Nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. the nurse should inform the client that which of the following manifestations indicate diabetes?

polyuria polydipsia neuropathy

a nures is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment finding should the nurse expect? a. postivie trousseau's sign b. 4+ deep tendon reflexes c. deep respirations d. hypoactive bowel sounds

D. hypoactive bowel sounds

a nurse is caring fro a clinet who has DKA. Which of the following should the nurse plan to administer a. 240 mL (8oz) of orange juice b. 1 ampule of 50% dextrose IV bolus c. NPH insulin 60 units subq D. regular insulin 20 units IV bolus

D. regular insulin 20 units IV bolus

a nurse is reviewing the lab report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following lab findings should the nurse identify as a positive outcome of the treatment?

Decreased sodium

a nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin

a nurse is admin meperidine IM in the right deltoid of a client. the nurse aspirates and pulls back blood in the syringe. Which of the following actions should the nurse take?

Dispose of the medication

a nurse in an ICU is planning care for a client who is in cardiogenic shock. The nurse should prepare to admin which of the following medications to increase cardiac output?

Dopamine

a nurse is preparing to admin a unit of packed RBCs to a client. which of the following actions should the nurse take?

remain with the client for the first 15 min of the infusion

a nurse in a providers office is assessing a client who has hypertension and take propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

report of night cough

a nurse is conducting an admission hx for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening?

shellfish allergy

a nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?

store the medication in its original container

a nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

take insulin even if you are unable to eat your regular diet

a nurse is assessing a client who is taking carvedilol for heart failure. Which of the following findings is the priority for the nurse to report to the provider?

weight gain

a nurse is providing discharge instructions to a client who has partial thickness burn of the hand. which of the following instructions should the nurse include?

wrap fingers with individual dressing

a nurse is assessing a client who has comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism?

Dyspnea

a nurse is reviewing the lab results of a client who has recent exposure to hep C virus. Which of the following tests should the nurse identify as indicating the presence of hep C antibodies?

Enzyme immunoassay (EIA)

a nurse i caring for a clinet who has peripherally inseted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC?

Flush the PICC line with 10 mL NS before and after medication admin

a nurse is assessing a client following the admin of IV penicillin G. which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction?

Flushing

a nurse is caring for a client who has cervical spinal cord injury sustained 1 month ago. which of the following manifestations indicates that the client is experiencing autonomic dysreflexia?

Heart rate 52/min

a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. which of the following findings is an adverse effect of this medication?

Hypokalemia

a nurse is caring fro a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following finds as a manifestation of cardiogenic shock?

Hypotension

a nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching

I will count my heart beats before taking this medication

a nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statement indicates an understanding of the teaching?

I will monitor my blood pressure while taking this medication

a nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. which of the following values should the nurse identity as a desired outcome for this therapy

INR 2.5

a nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicated an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following info should the nurse provide?

Increase fluid intake

a nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock?

Increased Heart rate

a client who has emphysema is receiving mechanical ventilation. the client appears anxious and restless, and the high-pressure alarm is sounds. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for him

a nurse is planning care for a client who has sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the clients room

a nurse is caring for a client who has portal hypertension. the client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs

a nurse is receiving report on a client who is postop following an open repair of Zenker's diverticulum/ The nurse should anticipate the surgical incision to be in which of the following locations?

A- near the throat

A nurse is caring fro a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? a. extremity cool upon palpation b. serosanguineous drainage on the dressing c. capillary refill of 2 seconds d. client report of discomfort when moving toes

A. extremity cool upon palpation

a nurse is providing teaching to a client who has recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

Consume at least 30 g of fiber daily

a nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity

a nurse is planning care for a client who has community acquired pneumonia. Which of the following interventions should the nurse include in the plan of care

Monitor the client for confusion