ATI Fundamentals

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client?

Acidosis... Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly.

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

Advise the client to tuck his chin downward

A nurse collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors increases the clients risk of developing breast cancer?

Age over 50 years

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include?

Avoid IM injections. IM injection which can increase the client's risk of bleeding

A nurse is providing discharge teaching to a client who has HIV. Which of the instructions about infection prevention should the nurse include?

Avoid large gatherings of people. Clean toothbrush by running through the dishwasher. Avoid digging in the garden

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care?

Avoid salty foods

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching?

Bear weight on both of your legs. The client should keep 3 points on the ground at all times. Therefore he must be able to bear weight on both legs.

A nurse is assessing for disseminated intravascular coaglulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect?

Bleeding at the venipuncture site. Petechiae on the chest and arms. Abdominal distension.

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

Brainstem serves as the respiratory control center.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. To allow the use of proper body mechanics and reduce the risk of self-injury

A nurse is preparing an in-service presentation about assessing clients who are having an acute MI. What is the most common assessment finding with acute MI?

Substernal chest pain

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take?

Perform an Allen's test prior to obtaining the specimen

A nurse is caring for an older client who had an acute MI. When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors?

Peripheral vascular resistance increases. This results from calcification and loss of elasticity of the blood vessels.

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect?

Petechiae and ecchymosis

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is caring for a client who recently has chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate?

Prohibit visitors from bringing fresh flowers and plants into the client's room Ensure thorough cleaning of the client's room and bathroom daily Use dedicated equipment such as stethoscopes

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?

Prolong QT intervals.

A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review?

Prothrombin time (The desired effect is a decrease in the PT time++

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is changing the dressing for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate.

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis..the ability to identify an objects size, shape, and texture via tactile sensation.

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction equipment

A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?

Sudden oliguria

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure.

A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan?

Initiate range of motion exercises to maintain mobility ad prevent contractures

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?

Leukopenia,

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors with have a significant impact on the plan of care for this client?

Lung cancer usually has metastasized before the client presents with symptoms.

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse. Alenolol is a beta blocker and can decrease the client's heart rate.

A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). 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 caring for a client who is having a possible MI. Which of the following findings should the nurse identify as an associated manifestation of an MI?

Nausea Chest pain Pain in the jaw, shoulder or abdomen

A nurse is examining the ECG of a client who is having an acute MI. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations?

Necrosis

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy?

Pacytopenia (a deficiency of WBCs, RBCs, and platelet count)

A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which of the following foods?

Eggs. Rich in Vit. B12

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

Elevated LDL levels. Desirable LDL level is <100 mg/dL

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take?

Encourage the client to cough. Doing so often clears this adventitious sound.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express thoughts about death and dying

A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues?

Epidermis

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses. This is critical in order to determine adequate blood supply to the foot.

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of the client's routine health screening?

Eye examination every 2 years.

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome?

Facial edema

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor is the eye. This manifestation is consistent with which of the following eye disorders?

Glaucoma

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find?

Hardening along the blood vessel Tenderness in the calf Increased leg circumference

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?

Hct 55% Normal value is 45-52 Elevated Hct indicates hypovolemia

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid It absorbs exudate and produces a moist environment that will facilitate healing

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease?

Hypertension Diabetes Mellitus Hyperlipidemia Tobacco smoking

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers.

A nurse on a medial-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?

Increased coughing

A nurse is performing an admission assessment for a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find?

Abdominal cramps

A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately.

Abdominal pain in the left upper quadrant.

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder?

Absence of hair on the legs. This indicated poor arterial circulation to that area.

A nurse is providing discharge teaching to a client following an open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

"I will change the catheter drainage bag once a week."

A nurse is providing reaching about lifestyle changes to a client who experienced a MI and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

"Before taking my medication, I will count my radial pulse rate."

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy."

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

"I am going to listen to your abdomen." The nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered.

A nurse is teaching a client who is using a patient controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

A nurse is providing teaching to a client who has a diagnosis of hep A. Which of the following statements by the client indicates an understanding of the teaching?

"I should stop eating raw clams." Individuals who eat raw or steamed shellfish are at an increased risk of acquiring hep A

A nurse is caring for a middle-ages adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare person identity with others. (They usually feel more comfortable with themselves)

The nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care?

Change the collection pouch in the early morning. (When urine output is reduced)

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an ice pack to the affected area

A nurse is completing an assessment for a client who has a history of unstable angina. Which of the following findings should the nurse expect?

Chest pain last for longer than 15 mins. This is due to reduced blood flow in a coronary artery

A nurse is preparing to administer a TB skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

Circle the injection area with a pen. This is done to ensure the nurse will examine the correct site

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are ages 65 or older are reluctant to report pain

A charge nurse is teaching adult CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presence of the client's gag reflex. This is done to determine the risk of aspiration and especially important for clients who are unconscious.

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground. Can be either both feet or a foot and the cane.

A nurse is providing teaching about crutches to a client who has a fracture of the right food. Which of the following instructions should the nurse include?

"Keep the rubber crutch tips securely in place." (Replace them when they show signs of wear)

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions?

"Physical activity is good for me, but I need to avoid overexertion."

A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide?

"The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."

A nurse is providing teaching to a client who has a new prescription for alprazolam. Which of the following items is a priority for teaching?

"This medication can affect your ability to drive or handle mechanical equipment."

A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make?

"Variant angina can cause changes on your electrocardiogram"

A nurse is preparing a client for cardiac catheterization. Which of the following piece of information should the nurse give the client before the procedure?

"You'll have to lie flat for several hours after the procedure." "You'll receive medication to relax you before the procedure." "You'll have to keep your leg straight after the procedure."

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse?

A leak within the ventilator's circuitry

A nurse is collecting a health history form a female client who is undergoing screening for breast cancer. Which of the following increases the client's risk of developing cancer?

Age over 50 years

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear.

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position.

A nurse in an urgent-care center is caring for a 15 year-old client whose symptoms suggest a STI. The clients parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Ask the adolescent to sign the consent form. In situations such as STI and substance use disorders.

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 pulsus paradoxus.

A nurse in an urgent care clinic is collecting date from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

Dry cough During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications?

Dysrhythmias

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep-tendon reflexes (12.7 is above the expected range)

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits. The nurse should first assess the clients readiness to commit to a change in behavior

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis or polyuria is the excretion of a high volume of urine.

A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer?

The client uses tabacco

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration?

The clients ID number The clients name ABO compatibility Rh compatibility

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?

Third-degree frostbite

A nurse is planning a presentation at a community center about risk factors for cancer. Which of the following types of cancer should the nurse include when discussing familial clustering of specific types of cancer?

Types of cancers that typically demonstrate a familial tendency include Breast, Colorectal, Ovarian, and Prostate

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect?

Unilateral, lacalized, nodular skin lesions

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute MI. Which of the following indicators should the nurse identify to confirm reperfusion?

Ventricular dysrhythmias

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal (It contains thick gluteal muscles and does not contain major nerves of blood vessels)

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular. These sounds are soft and low pitched.

A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client?

Vitamin B12

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37*C (98.6*F) This minimizes discomfort and vascular constriction

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood