ATI Exam 2 Questions

Pain A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis due to increased respiratory rate and blowing off CO2 (hyperventilation)

Excessive aspirin ingestion A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Acidosis and Resp. Alkalosis mixed disorder aspirin is salicylic ACID so excessive use leads to metabolic acidosis; in salicylate intoxications, the brain center stimulates hyperventilation as a compensatory measure

A nurse is planning to administer epoetin alfa to a client who has CKD. Which of the following should the nurse plan to review prior to administering the medication? A. BP B. Temperature C. Blood glucose levels D. Total protein level

A. BP - Epoetin alfa often causes HTN, which can lead to stroke or other complications

A nurse is caring for a client who has CKD. The kidneys regulate body fluids as well as assisting with with of the following functions? A. Regulation of Acid balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed to grow

A. Regulation of Acid balance - kidneys help balance by retaining bicarbonate as they excrete hydrogen ions

DKA A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Acidosis ketones are biproduct of fat breakdown

pulmonary embolism A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis increased respiratory rate leads to decreased CO2

Fever A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis increased respiratory rate leads to decreased CO2 (hypoventilation)

COPD A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis air trapping and hypercapnia (high CO2) is primary pathophysiology

Opioid overdose A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis due to respiratory depression/ CO2 is retained (hypoventilation)

A nurse is assessing an infant who has untreated congenital hypothyroidism. Which of the following manifestations should the nurse expect? A. Constipation B. Hyperreflexia C. Oily skin D. Hyperthermia

A. Constipation

A nurse is reviewing the lab reports of a client and notes an elevated thyroid-stimulating hormone level. Which of the following findings should the nurse expect? A. Bradycardia B. Tremors C. Low grade fever D. Diaphoresis

A. Bradycardia - elevated TSH level indicates hypothyroidism

A nurse is caring for a group of clients on a medical surgical unit. Which of the following disorders should the nurse identify as increasing the clients metabolic needs? A. COPD B. Hypothyroidism C. Cancer D. Parkinson's Disease E. Major Burns

A. COPD C. Cancer D. Parkinson's Disease E. Major Burns

A nurse is caring for a client who has AKI. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood Pressure C. Specific gravity D. Intake and output

A. Daily weight - a gain or loss of 1kg indicates a gain or loss of 1L of fluid, therefore weighting the client daily will provide the most accurate fluid status measurement

A nurse is caring for a child who has electrical burns on the lower arms and hands. Which of the following findings indicates the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20 D. Minimal pain

A. Dark urine - Can be an indication of myoglobinuria. It results from the elimination of waste products from muscle damage and can cause renal failure

A nurse is caring for a client who has a new RX for levothyroxine to treat hypothyroidism. Which of the following findings should the nurse identify as an indication that the client requires intervention? A. Heart rate 106 B. Dry Skin C. Oral temp of 98.2 D. Lethargy

A. Heart rate 106

A nurse is caring for a client who has manifestations of acute tubular necrosis following a kidney transplant. Which of the following interventions should the nurse anticipate? A. Hemodialysis B. Biopsy C. Immunosuppression D. Ballon angioplasty E. Surgical repair

A. Hemodialysis B. Biopsy C. Immunosuppression

A nurse is assessing a client who is 1 week PO from a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection? A. High BP B. CRT .8 C. NA 137 D. UO 100mL/hr

A. High BP - due to the kidneys role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension

A nurse is teaching a client who has CKD about predialysis dietary recommendations. The nurse should recommend restricting which intake. A. Protein B. Carbs C. Fats D. Calcium

A. Protein - most clients who have CKD need to restrict protein intake. Predialysis protein restriction can help preserve some kidney function

A nurse in the ED is assessing a client who has extensive burns on her face. Which of the following assessments should the nurse perform first? A. Estimation of burn injury B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output

B. Characteristics of the cough and sputum - ABCS is priority. A client who has burns to the face is at risk for pulmonary injury and development of a brassy cough can indicate an impending loss of airway

A nurse is caring a client who is in the oliguric stage of AKI. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? A. Administer an analgesic to the client B. Check the clients electrolytes C. Measure weight D. Restrict the clients protein intake

B. Check the clients electrolytes - Urgent versus nonurgent priority setting framework

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following imbalances should the nurse monitor? A. HyperCa B. HyperK C. HypoMg D. HypoPhosphatemia

B. HyperK

A nurse is preparing an in service program about the stages of AKI. WHich of the following pieces of information should the nurse include about prerenal azotemia? A. Prerenal azotemia begins prior to the onset of symptoms B. Interference with renal perfusion causes prerenal azotemia C. Prerenal azotemia is irreversible, even in the early stages D. Infections and tumors cause prerenal azotemia

B. Interference with renal perfusion causes prerenal azotemia - prerenal azotemia results from interference with renal perfusion, such as from heart failure or hypovolemic shock.

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss

B. Involuntary muscle spasms - this can occur if the parathyroid glands are damaged or removed during a thyroidectomy

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as part of an effective conference? A. the planning process for the conference is centered on the nursing staff B. Other health care professionals are in attendance at the conference C. Controversial opinions regarding the plan of care are not tolerated during the conference D. THe conference is focused on a discussion of the client's health care issues with minimal attention to resolving them

B. Other health care professionals are in attendance at the conference

A nurse in the emergency department is admitting a child who has full thickness burns over 45% of his body. Which of the following actions should the nurse take first? A. Administer IV morphine B. Administer topical antimicrobials C. Administer IV fluid replacement D. Administer tetanus prophylaxis

C. Administer IV fluid replacement - the greatest risk to this child is an injury from hypovolemic shock; therefore the first action the nurse should take after ensuring the child has a patent airway is to administer IV fluid replacement therapy.

A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? A. Purple striae on the chest and abdomen B. Butterfly rash on the face C. Bronze pigmentation of the skin D. Jaundice of the face and sclera

C. Bronze pigmentation of the skin

A nurse is reviewing the labs of a client who has CKD. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? A. HyperNa B. HyperCa C. HypoMg D. HyperK

D. HyperK - Manifestations include palpitations, dysrhythmias, nausea, and muscle weakness

A nurse is teaching a client who has Addison's disease about the RX for hydrocortisone. Which of the following statements should the nurse include in the teaching about this medication? A. You may need to take a lower dosage when you are ill or stress B. Take this medication before going to bed C. Carry a supply of pills and a single use injectable preparation with you at all times D. You will need to stop this medication before routine procedures

C. Carry a supply of pills and a single use injectable preparation with you at all times - Doing this to avoid Addisonian crisis

A nurse is providing teaching to a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client on which of the following findings indicates thyrotoxicosis. A. Weight gain B. Constipation C. Chest pain D. Fatigue

C. Chest pain - Thyrotoxicosis can result if a client takes too much levothyroxine. S&S include chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis.

A nurse is reviewing lab findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. HypoK B. HyperCa C. Decreased plasma CRT levels D. Metabolic acidosis

D. Metabolic acidosis

A nurse plans to administer fluids to a client with 25% burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? A. Whole blood B. Lactated Ringers C. Dextran 40 in NS D. .45 NS

D. .45 NS - is a hypotonic solution and is contraindicated for clients who have burns. Administering a hypotonic solution to this client can cause 3rd spacing of fluid

A nurse in the ED is caring for a 4 yr old who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. cover the child's wounds with a clean, dry cloth B. Establish IV access with a large bore catherter C. Provide reassurance to the childs parents D. Determine the childs breathing patterns

D. Determine the childs breathing patterns

A nurse is monitoring a client who has Graves disease for the development of a thyroid storm. The nurse should report which of the following findings to the provider. A. Constipation B. Headache C. Bradycardia D. Hypertension

D. HYpertension

A nurse is assessing a client who has AKI. According to the RIFLE system, which of the following findings indicates that the client has end stage kidney disease? A. <.5 of urine output for 12 hrs B. No urine output for 12 hrs C. No UO without renal replacement therapy for 4 - 12 weeks D. No UO without renal replacement therapy for more than 3 months

D. No UO without renal replacement therapy for more than 3 months

A nurse is caring for a client who is taking a RX for glucocorticodi adrenal replacement medication for Addison's disease. What is an adverse effect of this medication? A. Weight loss B. Hypotension C. Lethargy D. Osteoporosis

D. Osteoporosis

A nurse is rewarming a client following coronary artery bypass graft surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade

A. Acidosis - Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1C per hour.

A nurse is providing dietary teaching a client who has end stage CKD about nutrients that client should increase in her diet. A. Calcium B. Phosporous C. Potassium D. SOdium

A. Calcium - clients who have CKD can develop hypoCa due to the reduced production of active vitamin D, which is needed for calcium absorption

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances. A. HyperK B. HypoNa C. HyperCa D. HypoMg

A. HyperK - Respiratory acidosis can result in high K levels due to K shifting out of the cells into the extracellular fluid

A client who has emphysema and chronic resp. acidosis. The nurse should monitor the client for which electrolyte imbalance? A. HyperK B. HypoNa C. HyperCa D. HypoMg

A. HyperK - chronic resp. acidosis can result in high K levels due to K shifting out of the cells into the extracellular fluid

A nurse is assessing a client who has Addison's disease. Which of the following findings should the nurse expect? A. Hypotension B. Weight gain C. Sugar craving D. Pale skin tone

A. Hypotension

A nurse is planning care for a client who has deep and full-thickness burns on 40% of his body and is in the acute phase of burn. Which of the following interventions should the nurse include in the plan? A. Initiate ROM B. Use clean techniques to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest

A. Initiate ROM - The nurse should begin performing active and passive ROM exercises with the client to maintain mobility and prevent contractures

A nurse is caring for a client who has been diagnosed with an Addisonian crisis and has a blood pressure of 74/42. Which of the following prescriptions should the nurse anticipate? A. Desmopressin B. Hydrocortisone C. Dopamine D. Furosemide

B. Hydrocortisone - this medication helps to assist with replacing cortisol levels

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor for which A. Resp. Alkalosis B. Resp. Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

B. Resp. Acidosis - client is unable to exhale CO2 due to a loss of elastic recoil in the lungs

Aggressive Mechanical Ventilation A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

B. Resp. Alkalosis settings are too aggressive leading to blowing off too much CO2 and need to turn down respiratory rate (hyperventilation)

A nurse is planning care for a client who has SIADH with mild manifestations. The nurse should expect the provider to prescribe which of the following medications? A. Chlorpropamide B. Tolvaptan C. Vasopressin D. Desmopressin

B. Tolvaptan - promotes the excretion of water, which helps correct the fluid imbalance in clients who have SIADH

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? A. Insert an indwelling catheter B Administer pain medication to the client C. Change the clients position D. Place the drainage bag above the clients abdomen

C. Change the clients position - Ensure that the clamp is open and the tubing is not kinked and should reposition the client to facilitate the drainage of the solution from the cavity

A nurse is reviewing the medical record of a client receiving hydrochlorothiazide. The nurse should expect to find an improvement in which of the following conditions as a result of this medication. A. Gouty arthritis B. Dehydration C. DI D. Hypokalemia

C. DI - DI has a overproduction of urine. Thiazides reduce urine production

A nurse is monitoring a client who has DI and was administered desmopressin. Which of the following findings should indicate to the nurse the client is experiencing an adverse effect of this medication? A. Thrist B. Nocturia C. Headache D. Heart palpitations

C. Headache - indicator of water intoxication, which can occur as a result of taking desmopressin. This medication causes fluid retention and places the client at risk of water intoxication

A nurse is monitoring a client who has SIADH. Which of the following findings should the nurse expect? A. Polyuria B. Dehydration C. Hyponatremia D. Hyperthermia

C. Hyponatremia - SIADH causes excessive release of ADH. As a result of the excess ADH, the client retains water. which causes dilutional hyponatremia

A nurse is monitoring a client who has SIADH. Which of the following findings should the nurse expect? A. Polyuria B. Dehydration C. Hyponatremia D. Hypernatremia

C. Hyponatremia - caused by the excessive release of ADH. As a result of the excess ADH, the client retains water, which causes dilutional hyponatremia

A nurse is caring for a client who has full thickness burns and covering 63% of her body and smoke inhalation. Which of the follwoing nursing actions is top priorty? A. Monitor I&O B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake

C. Monitor respiratory status

A nurse is caring for a client who has DI. For which of the following findings should the nurse monitor? A. Proteinuria B. Oliguria C. Polyuria D. Glycouria

C. Polyuria

A nurse is assessing a client who has hypothyroidism and takes levothyroxine. Which of the following findings indicates that the clients experiencing acute levothyroxine overdose? A. BRadycardia B. Cold intolerance C. Tremor D. Hypothermia

C. Tremor - Thyrotoxicosis can result if a client takes too much levothyroxine. S&S include chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, and diaphoresis.

A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? A. Wernicke's area B. Cerebral cortex C. Basal ganglia D. Hypothalamus

D. Hypothalamus - located below the cerebrum of the brain and is responsible for the regulation of body temperature.

Diarrhea A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Acidosis excessive loss of bicarbonate

Panic Attack A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis due to increased respiratory rate/ CO2 is blown off (Hyperventilation)

A nurse is checking the labs of a client who has CKD. The nurse should expect elevation in which of the following values? A. K and MG B. Ca and Bicarbonate C. Hemoglobin and Hematocrit D. Artial Ph and PaCO2

A. K and MG

A nurse is teaching a client who has CKD. Which of the following instructions should the nurse include? A. Limit fluid intake B. Limit caloric intake C. Eat a diet high in phosphorus D. Eat a diet high in protein

A. Limit fluid intake

A nurse is providing teaching to a client who has CKD with an AV fistula for dialysis and a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching? A. Reduces blood pressure B. Inhibits clotting of fistula C. Promotes RBC production D. Stimulates growth of neutrophils

C. Promotes RBC production - Epoetin alfa stimulates erythropoiesis in the bone marrow to increase RBC production and reduce anemia. Anemia is common in clients who have chronic kidney failure since erythropoietin is produced by the kidney.

Guillain-Barre syndrome A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis neuromuscular deficit can lead to hypoventilation and retained CO@

Obesity A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis obesity leads to hypoventilation and retain CO2

obstructive sleep apnea A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis obstruction of airway leads to retained CO2

Traumatic Brain injury A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Acidosis respiratory rate is decreased

High altitudes A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis SOB leads to increased respiratory rate and blowing off CO2 (hyperventiliation)

Kussmal Respirations A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Resp. Alkalosis compensatory in response to metabolic acidosis Note: it can be the opposite with metabolic alkalosis there can be a compensatory slowing of respirations to hold CO2

Renal Failure A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Acidosis kidneys do not excrete hydrogen ions well

Septic Shock A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Acidosis poor perfusion secondary to hypovolemia leads to buildup of lactic acidosis

Antacid or PPI use A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Alkalosis leads ti excess bicarbonate as acid is neutralized or not synthesized

Gastric suctioning A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Alkalosis loss of gastric acid

Repeated Vomiting A. Resp. Acidosis B. Resp. Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

Metabolic Alkalosis loss of gastric acid

A nurse is planning care for a client who has Cushing's due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care? A. Check the clients BG for hypoglycemia B. Check the clients urine specific gravity C. Weight the client weekly D. Insert an indwelling catheter for the client

B. Check the clients urine specific gravity - assess for fluid volume overload

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen

B. Pig skin

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hours B. Position the child on a colling blanket and cover her with a sheet C. Place the child in a tub filled with water to cool her. Water is 80 degrees D. Asses the child's temperature every 2 hours during the cooling

B. Position the child on a colling blanket and cover her with a sheet

A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T wave B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals -Manifestations include tingling , numbness, tetany, seizures, prolonged QT intervals

A nurse is caring for a child who adheres to a vegetarian diet and has superficial partial thickness burns. The nurse should recommend which of the following food choices is due to the high protein content. A. Medium baked potato B. Wheat bagel with jam C. Orange D. Peanut butter and apples

D. Peanut butter and apples - increased protein, helps promote the healing process

A nurse assesses a client who sustained superficial partial-thickness and deep partial thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30ml/hr D. Temperature of 102.4

D. Temperature of 102.4 - An elevated temperature is an indication of infection. Sepsis is a critical finding following a major burn injury.