ATI Perfusion Qs

A nurse is preparing to administer atenolol 25 mg PO every 12 hr. The amount available is atenolol 50 mg/tab. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tablets

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

15 mL

The client comes to the ED saying, "I am having a heart attack." Which question is most pertinent when assessing the client? A. Can you describe the chest pain? B. What were you doing when the pain started? C. Did you have a high fat meal today? D. Does the pain get worse when you lie down?

A. Can you describe the chest pain?

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A. Abnormally prominent U wave

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following? A. Arterial insufficiency B. Venous insufficiency C. Within the expected range D. Thrombus formation in the vein

A. Arterial insufficiency

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? (Select all that apply.) A. Check peripheral pulses in the affected extremity. B. Place the client in high-Fowler's position. C. Measure the client's vital signs every 4 hr. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr

A. Check peripheral pulses in the affected extremity. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Check vital signs before transfusion. B. Insert an IV with a 19-gauge needle. C. Prime the blood tubing with dextrose 5% in water. D. Transfuse the blood product within 5 hr after removing it from refrigeration. E. Check the expiration date of the blood product with a second nurse.

A. Check vital signs before transfusion. B. Insert an IV with a 19-gauge needle. E. Check the expiration date of the blood product with a second nurse.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. Blood pressure 84/50 mm Hg C. Anuria D. Petechiae

A. Confusion Rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not wear tight clothing over the insertion area. D. Request to be scanned with a handheld metal detector when in the airport. E. Do not have a microwave oven in the home.

A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area.

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.) A. Decreased platelet count B. ​Increased hemoglobin count C. Decreased leukocyte count D. Increased platelet count E. Decreased erythrocyte count

A. Decreased platelet count C. Decreased leukocyte count E. Decreased erythrocyte count

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Defibrillation B. Airway management C. Epinephrine administration D. Amiodarone administration

A. Defibrillation Rationale: The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A nurse is evaluating the laboratory report for a client who has severe diarrhea and a fever. Which of the following laboratory findings should the nurse identify as an indication that the client has a parasitic infection rather than a bacterial infection? A. Elevated eosinophil count B. Decreased neutrophil count C. Elevated hemoglobin level D. Decreased albumin level

A. Elevated eosinophil count Rationale: Eosinophils are a type of white blood cell which increases in the presence of parasitic infection and allergic reactions.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? A. Exercise at least three times per week. B. Take diuretics early in the morning and before bedtime. C. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. D. Take naproxen for generalized discomfort.

A. Exercise at least three times per week. Rationale: The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea

A. Fatigue

A nurse is reviewing the laboratory results of a client who has acute radiation syndrome and notes the client has leukopenia. Which of the following assessment findings should the nurse identify as being consistent with leukocytosis? A. Fever B. Bruising C. Pallor D. Petechiae

A. Fever

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction? A. Generalized urticaria. B. Blood pressure 184/92 mm Hg. C. Distended jugular veins. D. Bilateral flank pain.

A. Generalized urticaria.

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.

A. 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 assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature

A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication Rationale: Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention.

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? A. Oncology nurse B. Assistive personnel C. Senior nursing student D. Phlebotomist

A. Oncology nurse

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? A. Recombinant B. Packed RBCs C. Prophylactic antibiotics D. Fresh frozen plasma

A. Recombinant Rationale: The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? A. Reduction of T-wave amplitude B. Shortening of P-wave duration C. Widening of the QRS complex D. Restoration of QRS complex amplitude

A. Reduction of T-wave amplitude Rationale: Polystyrene sulfonate should bring the potassium level back to the expected reference range of 3.5-5.0 mEq/L. Hyperkalemia causes peaked T waves and sometimes a widened QRS on ECG, so resolution of the potassium imbalance should restore these ECG changes to baseline.

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.) A. Saw palmetto B. Flaxseed oil C. Glucosamine D. Black cohosh E. Gingko biloba

A. Saw palmetto C. Glucosamine E. Gingko biloba

A nurse is caring for a client 1 hr following a subtotal thyroidectomy. In which of the following positions should the nurse place the client? A. Semi-Fowler's B. Dorsal recumbent C. Supine D. Sims'

A. Semi-Fowler's

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? A. Shallow respirations B. Hypertensive crisis C. Diarrhea D. Hyperreflexia

A. Shallow respirations Rationale: A client's shallow respirations are a sign of weakness in the accessory muscles of breathing, due to hypokalemia.

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions? A. Spontaneous bleeding B. Oliguria C. Hyperactive deep tendon reflexes D. Infection

A. Spontaneous bleeding Platelet ref range: 150,000-400,000

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? A. Stop the infusion of blood. B. Inform the provider C. Obtain a urine specimen. D. Notify the laboratory.

A. Stop the infusion of blood.

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? A. The P wave falls before the QRS complex. B. The T wave is in the inverted position. C. The P-R interval measures 0.22 seconds. D. The QRS duration is 0.20 seconds.

A. The P wave falls before the QRS complex. Rationale: The nurse should recognize that in normal sinus rhythm the P wave, representing atrial depolarization, falls before the QRS wave.

The nurse has received shift report. Which client should the nurse assess first? A. The client diagnosed with CAD complaining of severe indigestion. B. The client diagnosed with HF who has 3+ pitting edema. C. The client diagnosed with A. Fib whose apical pulse is 110 and irregular. D. The client diagnosed with sinus bradycardia who is constipated.

A. The client diagnosed with CAD complaining of severe indigestion.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub C. The third heart sound (S3) D. A split second heart sound S2

A. The fourth heart sound (S4)

A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select all that apply.) A. Verify the provider's prescription with another RN. B. Confirm that the room number matches the medical record. C. Scan the barcode on the client's identification band. D. Ask the client to verbalize if blood type is Rh-negative or positive. E. Compare client identification number to the blood component tag number.

A. Verify the provider's prescription with another RN. C. Scan the barcode on the client's identification band. E. Compare client identification number to the blood component tag number.

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? A. Vertigo B. Uremia C. Blurred vision D. Dyspnea

A. Vertigo

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A. "Reaching your goal blood pressure will occur within 2 months." B. "Diuretics are the first type of medication to control hypertension." C. "Limit your alcohol consumption to three drinks a day." D. "Plan to lower saturated fats to 10 percent of your daily calorie intake."

B. "Diuretics are the first type of medication to control hypertension."

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will have to stay in bed for several hours after the procedure." B. "I will turn my head in the opposite direction during insertion." C. "I will need to hold my breath when they first put the needle in." D. "I will call the clinic if I have persistent hiccups."

B. "I will turn my head in the opposite direction during insertion."

A nurse is teaching a client scheduled for an activated partial thromboplastin time (aPTT). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to skip breakfast until after the test is complete." B. "It measures deficiencies in clotting factors." C. "If my levels are too low, I am at an increased risk for bleeding." D. "This test will help my provider adjust my warfarin dosages."

B. "It measures deficiencies in clotting factors."

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? A. "I will take my pulse weekly." B. "The pacemaker can be checked from home by using the telephone." C. "My pacemaker will need reprogramming if I stand too close to a microwave oven." D. "The next pacemaker check will be when the batteries need to be replaced."

B. "The pacemaker can be checked from home by using the telephone." Rationale: The initial pacemaker check is performed at the clinic. Following this initial examination, follow-up pacemaker checks can happen remotely from the client's home. Using a telephone transmitting device, the client can transmit basic information electronically from the pacemaker to the clinic. The client will return to the clinic annually for a more thorough pacemaker check.

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia

B. Atrial fibrillation Rationale: Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? A. Prolonged bleeding B. Cellular hypoxia C. Impaired immunity D. Fluid retention

B. Cellular hypoxia Ref ranges Hemoglobin: 12-18 g/dL Hematocrit: 37-52%

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? A. Obtain the client's blood glucose every 12 hr. B. Change the IV tubing every 24 hr. C. Change the IV site dressing every 4 days. D. Weigh the client every other day.

B. Change the IV tubing every 24 hr.

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? A. Attach defibrillator pads to the client. B. Check for a carotid pulse. C. Begin chest compressions. D. Deliver two breaths.

B. Check for a carotid pulse.

A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion? A. Hypothermia B. Chills C. Nystagmus D. Bradycardia

B. Chills

A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? A. Apical pulse rate is different than the radial pulse rate B. Decrease in systolic pressure by more than 10 mm Hg during inspiration C. Increase in heart rate by 20% when moving from sitting to standing D. Drop in systolic BP by 20 mm Hg when changing positions

B. Decrease in systolic pressure by more than 10 mm Hg during inspiration Rationale: The nurse should expect a client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or cardiac tamponade.

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider? A. Splinter hemorrhages to the nails B. Dyspnea C. Fever D. Clusters of petechiae in the mouth

B. Dyspnea

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Increased pulmonary artery wedge pressure (PAWP). D. Decreased specific gravity

B. Elevated central venous pressure (CVP). Rationale: CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? A. Transient ischemic attack (TIA) B. Hemorrhagic stroke C. Thrombotic stroke D. Embolic stroke

B. Hemorrhagic stroke Rationale: A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A. Increased heart rate B. Increased urine output C. Decreased blood pressure D. Decreased blood glucose level

B. Increased urine output Rationale: Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. The nurse should identify an increase in client's urine output as an indication that the medication is effective.

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.) A. Keep the client NPO after midnight. B. Inspect the electrode pads. C. Wash the skin with plain water before placing the electrodes. D. Instruct the client not talk during the test. E. Administer an analgesic prior to the procedure.

B. Inspect the electrode pads. D. Instruct the client not talk during the test.

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching? A. Teach the client how to use the PCA pump. B. Instruct the client about the use of a sequential compression device. C. Discuss the visitation policy. D. Review the pain scale.

B. Instruct the client about the use of a sequential compression device.

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect? A. Thin, pliable toenails B. Leg pain at rest C. Hairy legs D. Flushed, warm legs

B. Leg pain at rest

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet

B. MRI of the chest

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

B. Massaging her legs

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? A. Atorvastatin B. Metformin C. Nitroglycerin D. Carvedilol

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

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) A. BMI of 20 B. Oral contraceptive use C. Hypertension D. High calcium intake E. Immobility

B. Oral contraceptive use E. Immobility

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? A. Sodium 136 mEq/L B. Potassium 2.3 mEq/L C. Chloride 99 mEq/L D. Calcium 10 mg/dL

B. Potassium 2.3 mEq/L Ref range: 3.5-5 mEq/L

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/84 mm Hg places him in which of the following categories? A. Within the expected reference range B. Prehypertension C. Stage 1 hypertension D. Stage 2 hypertension

B. Prehypertension

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? A. Put a nitroglycerin tablet under the tongue. B. Stop activity immediately and rest. C. Document what caused the angina. D. Notify the health-care provider immediately.

B. Stop activity immediately and rest.

A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first? A. Notify the provider. B. Stop the infusion. C. Collect a urine sample from the client. D. Return the platelet bag and tubing to the blood bank.

B. Stop the infusion.

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include? A. The client cannot travel by air due to security screening. B. The client should hold his cell phone on the side opposite the ICD. C. The client should avoid the use of small electric devices. D. The client can carry his ICD in a small pocket.

B. The client should hold his cell phone on the side opposite the ICD.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? A. The laboratory values are within the expected reference range. B. The laboratory values are prolonged. C. The laboratory values are decreased. D. The laboratory values are the same as the previous test values.

B. The laboratory values are prolonged. Rationale: These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding? A. The drip chamber with filter is filled completely with blood. B. The packed RBCs are connected by Y tubing to normal saline. C. The blood has been infusing steadily for 5 hr with no client symptoms. D. A medication is being administered IV through the injection site closest to the client.

B. The packed RBCs are connected by Y tubing to normal saline. Rationale: The only intravenous fluid that can be used in the blood administration tubing is normal saline. It is used to prime the tube, and when the infusion is complete, it should also be used to clear the line. Y tubing allows for normal saline to infuse through one branch of the Y and packed RBCs through the other.

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider? A. Hct 45% B. WBC 1,700/mm3 C. Hgb 14.7 g/dL D. Platelets 160,000/mm3

B. WBC 1,700/mm3 Ref range 5,000-10,000

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving a vitamin K deficiency."

C. "DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? A. "You might feel a slight tingling while the test is being done." B. "The test will be complete in 30 to 60 minutes." C. "I will need to apply electrodes to your chest and extremities." D. "The radioactivity from the dye lasts only a few hours."

C. "I will need to apply electrodes to your chest and extremities."

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A. "I am gaining weight." B. "I am constipated." C. "My vision seems yellow." D. "My tongue is red and beefy."

C. "My vision seems yellow."

A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client? A. "I will be placing electrodes on your breasts." B. "Try to hold your breath until this procedure is complete." C. "Try to remain still once I have attached the gel pads." D. "I will lower the head of your bed so you can lie flat."

C. "Try to remain still once I have attached the gel pads." Rationale: It is very important for the client to understand the importance of lying still during the electrocardiogram. Lying still will prevent artifact from occurring and allow for clear results when interpreted by the provider.

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include? A. "You can resume regular exercise as soon as tomorrow." B. "The dressing should be changed within 12 hours of the procedure." C. "You will notice a small hematoma at the incision site." D. "Pain medication will not be necessary."

C. "You will notice a small hematoma at the incision site."

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every 12 hr

C. 0.9% normal saline IV at 50 mL/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Assess the client's level of consciousness. B. Administer epinephrine. C. Auscultate for wheezing. D. Monitor for hypotension.

C. Auscultate for wheezing. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

The client with coronary artery disease asks the nurse, "why do I get chest pain?" Which statement by the nurse is the most appropriate? A. There is ischemia to the myocardium as a result of hypoxemia. B. The heart muscle is unable to pump effectively to perfuse the body. C. Chest pain is caused by decreased oxygen to the heart muscle. D. Chest pain occurs when the lungs cannot adequately oxygenate the blood.

C. Chest pain is caused by decreased oxygen to the heart muscle.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.

C. Cover the wound with a moist, sterile gauze dressing. Rationale: The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question? A. Furosemide IVP to a client with a potassium level of 3.8 B. Digoxin orally to a client diagnosed with rapid atrial fibrillation. C. Enalapril orally to a client whose BP is 86/64 D. Morphine IVP to a client with chest pain and diaphoresis

C. Enalapril orally to a client whose BP is 86/64

A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin? A. Cranberry juice B. Aloe vera C. Feverfew D. Flaxseed

C. 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 providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily

C. Flexing her knees and feet frequently Rationale: Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? A. Asthma B. Aortic valve regurgitation C. Heart failure D. Aortic stenosis

C. Heart failure

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? A. Apnea B. Dysphagia C. Hypoxemia D. Pleural effusion

C. Hypoxemia Rationale: The nurse can expect to find the client with hypoxemia, which is decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange.

A charge nurse is teaching a group of nurses about clients who report using garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of these supplements? A. Decreased effects of antirejection medication B. Decreased effects of antianxiety medications C. Increased effects of oral anticoagulants D. Increased effects of antidepressant medications

C. Increased effects of oral anticoagulants Rationale: The nurse should include that garlic, ginger, and ginkgo biloba can all interfere with the effects of oral anticoagulants and thus increase the risk of bleeding.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Anuria C. Increased respiratory rate D. Decreased level of consciousness

C. Increased respiratory rate Rationale: When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.

A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identity that a reading of 15 mm Hg is an indication of which of the following conditions? A. Fluid volume deficit B. Right ventricular failure C. Mitral regurgitation D. Afterload reduction

C. Mitral regurgitation Rationale: Hemodynamic monitoring allows the nurse to monitor the pressures within the heart and the great vessels. The PAWP reflects left atrial pressure. A reading of 15 mm Hg is above the expected reference range, which can indicate mitral regurgitation, hypervolemia, or left ventricular failure. The nurse should monitor for trends in value, which can be more reliable than individual values.

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? A. High-density lipoprotein (HDL) level of 70 mg/dL B. A diet high in potassium C. Obstructive sleep apnea (OSA) D. Taking benazepril

C. 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 performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 mm Hg

C. Skin tenting present

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion? A. Skin color B. Fluid intake C. Temperature D. Hemoglobin level

C. Temperature

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A. The client's ECG tracing shows irregular heart rate without P waves. B. The client has an aPTT of 80 seconds. C. The client experiences sudden weakness of one arm and leg. D. The client's urine output is cloudy and odorous.

C. The client experiences sudden weakness of one arm and leg.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction? A. The first 2 min B. The final 2 min C. The first 15 min D. The final 15 min

C. The first 15 min

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess? A. The coping ability of the client B. The client's bowel sounds 24 to 48 C. The surgical dressing D. The patency of the NG tube

C. The surgical dressing Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the assessment priority is monitoring the surgical dressing. Hemorrhage is a major complication postoperatively, so the nurse should assess for early indications of bleeding, such as visible blood stains on the surgical dressing. Covert manifestations of bleeding include rapid, thready pulse, tachycardia, and decreased urine output.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a lipid whose levels reflect the risk for coronary artery disease. C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic B. anti-inflammatory C. antiplatelet aggregate D. antipyretic

C. antiplatelet aggregate

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following? A. 2 hr B. 6 hr C. 8 hr D. 4 hr

D. 4 hr

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? A. Aplastic anemia is associated with a decreased intake of iron. B. Aplastic anemia results in an increased rate of RBC destruction. C. Aplastic anemia results in an inability to absorb vitamin B12. D. Aplastic anemia results from decreased bone marrow production of RBCs.

D. Aplastic anemia results from decreased bone marrow production of RBCs.

A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include in the plan? A. Encourage coughing, and deep-breathing. B. Allow the client to ambulate. C. Remove the eye patch during the day. D. Avoid reading and writing.

D. Avoid reading and writing.

The client is three hours post MI. Which data would warrant immediate intervention by the nurse? A. Bilateral peripheral pulses 2+ B. The pulse ox reading is 93% C. The urine output is 160 mL in the last 4 hours D. Cool, clammy, diaphoretic skin

D. Cool, clammy, diaphoretic skin

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? A. Dobutamine B. Methylprednisolone C. Furosemide D. Epinephrine

D. Epinephrine

A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain usually lasts longer than 20 min. B. The pain often radiates to the jaw or the back. C. The pain persists with rest and organic nitrates. D. Exertion and anxiety can trigger the pain.

D. Exertion and anxiety can trigger the pain.

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider? A. Platelets 156,000/mm3 B. PT 12 seconds C. PTT 64 seconds D. Fibrinogen 85 mg/dL

D. Fibrinogen 85 mg/dL Ref range is 170-340

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough

D. Hacking cough Rationale: A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Febrile B. Allergic C. Acute pain D. Hemolytic

D. Hemolytic Rationale: A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse.

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? A. Fluid overload B. Left ventricular failure C. Intracardiac shunt D. Hypovolemia

D. Hypovolemia Rationale: A low CVP indicates reduced right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or over diuresis.

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min. B. Decrease in the urinary output from 50 mL to 30 mL per hour. C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). D. Increase in the heart rate from 88 to 110/min.

D. Increase in the heart rate from 88 to 110/min.

A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions? A. Aortic regurgitation B. Mitral stenosis C. Aortic stenosis D. Mitral valve prolapse

D. Mitral valve prolapse Rationale: Although many clients who have mitral valve prolapse are asymptomatic, others report atypical chest pain, palpitations, exercise intolerance, dizziness, and syncope. Auscultation of a client who has mitral valve prolapse reveals a systolic click that is caused by a valve leaflet prolapsing into the left atrium.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Albumin D. Packed RBCs

D. Packed RBCs Rationale: Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

A nurse is caring for a female client who reports an increase in bruising. The nurse should Expect which of the following laboratory values? A. WBC 8,000 mm3 B. RBC 4.6 million/mm³ C. Hemoglobin 13.0 g/dL D. Platelets 110,000 mm3

D. Platelets 110,000 mm3 Ref range: 150,000-400,000