ATI Practice B

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nures should identify the need to revise the plan for which of the following clients?

A client who is postoperative following abdominal surgery and reports feeling that something popped when they coughed

A nurse is teaching a client about the use of a transcutaneous electrical nerve stimulation for the management of bone cancer pain. The nurse should explain that applying a TENS unit in the painful area has which of the following effects?

A tingling sensation replacing the pain

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Applying oxygen via face mask

A nurse is acaring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

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

INR 2.5

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

Ibuprofen can cause gastrointestinal bleeding in older adult clients

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching?

Increase fiber intake to avoid constipation

The nurse should first address the client's....... followed by the client's.......

Oxygenation Blood pressure

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PaCO2 56 mm Hg

Compartment syndrome in a client hwo has short leg cast. Which finding should nurse identify as manifestion of condition?

Pain that increases with passive movement

Vaginal hysterectomy 4 hr postoperative:

Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min

The nurse is caring for the client who has manifestations of............therefore; the priority finding foir the nurse to report is: ..............

Peritonitis Laboratory values

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following action should the nurse identify as the priority?

Place a tracheostomy tray at the bedside

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Place personal items, such as pictures, at client's bedside.

Nurse is caring for a client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.

Place the client in a high-fowlers position Place two rubber-tipped hemostats in the client's room Palpate the chest tube insertion site for subcutaneous emphysema Ensure that all chest tube connections are securely attached

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk of developing osteoporosis?

Prednisone

A nurse is assessing a client while suctioning a clients trach tube. Which of the following findigs should indicate to the nurse the client is experiencing hypoxia?

The client's heart rate increases

Nurse providing discharge to client who is to self administer heparin. Which statement by client indicates understanding?

I will use electric razor to shave.

Phenytoin 600 mg PO. Oral solution 125 mg/5mL. How many mL?

24

After reviewing the findings in the client's medical record, the nurse should first address the client's........ followed by the client's.......

Abdominal distention Acute pain

Caring for the client who is preoperative for an exploratory laparotomy. Select the 4 actiosn that the nurse should take:

Administer gentamicin 100 mg IV Administer dextorse 5% in lactated ringer's Contact the wound, ostomy, and continence nurse Administer phenytoin with a sip of water prior to the surgery

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

Airborne

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

Alternate application of heat and cold to the affected joints.

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

Avocados

A nurse is reviewing the lab results ofa client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

BUN 34 mg/dL

A nurse is caring for a client who has a positive culture for methiciilin-resistant Staphylococcus aureaus. Which of the following actions should the nurse take?

Bathe the client using chlorhexidine solution

Nurse is caring for client with pneumothroox and closed chest drainage system. Which finding is indication of lung re-expansion

Bubbling in water seal chamber has ceased.

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider?

Calf pain Numbness in arms Intense headache

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

Change position every hour.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states Last week I crashed my car because my vision suddenly became blurry. Which of the following actions is the nurses priority?

Check the client's neurologic status

A nurse is preparing to admin a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check the type and number of units of blood to administer.

The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses' note that indicate the client condition is improving?

Client reports pain as 3 on a scale of 0 to 10 Client reports shortness of breath has decreased Wound dressing is dry and intact Resporatory rate 24/min, BP 108/74, and oxygen sat 95% on 2 l/min via nasal cannula

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying

A nurse caring for a client TPN and NPO , has rx for capillary blood glucose AC and HS

Contact the provider to clarify the prescription

A nurse is caring for a client who has ICP and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Crackles heard on auscultation.

A nurse teaching family about care of parent who ahs new dx of Alzheimer's. Which of information should the nurse include?

Create complete outfits and allow the client to select one each day.

Client has terminal cancer. The client tells the nurse "I wish I could stop these treatments I'm ready to die."

Discontinuing is your wish if you choose to do so

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload?

Distended neck veins

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

Document that depolarization has occurred

A nurse is providing teaching to a client who has a new Rx for psyllium. Which of the following information should the nurse include in the teaching?

Drink 240 mL of water after administration.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea

A nurse is planning care for ac lient who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure.

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

Family members in the home should undergo TB testing.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?

Flex the foot every hour when awake

Presentation of atherosclerosis at health fair. Which recommendations should nurse plan to include?

Follow a smoking cessation program Maintain an appropriate weight Eat a low fat diet

Gingko biloba as herbal supplement. Which statement should the nurse make?

Gingo can cause an increased risk for bleeding.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL

Peripheral arterial disease, finding should expect?

Hair loss on lower legs

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80, bp 130/70, rr 16, and temp 96.8 F. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min

Complete the following sentence using the list of options: The client is most likely experiencing......as evidenced by the client's.....

Hemothorax Respiratory findings

Providing teaching to client with asthma about use of metered dose inhaler. The nuse should identify following client actions indicates understanding?

Holding breath for 10 seconds after inhaling

A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients?

Hypertension

During the emergent phase of burn care, the client is at risk for developing.........and........

Hypovolemia Respiratory failure

Nurse's Note: Complete the diagram, client admitted to med surg. Reports incisional pain as a 2 on scale of 0-10. Appears restless and frequently asks for water. Bilaterla lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of birght red drainage noted on surgical incision dressing

Hypovolemia; Insert large gauge IV & Initiate Fluid Challenge; Urine output & Blood pressure

A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupumture because it provides greater relief than pain medication. Which of the following statements hould the nurse make?

I can speak to the provider about incorporating acupuncture into your treatment plan.

Nurse is providing discharge teaching to the client. Which of the following statements made by the client indicates an understanding of the teaching? Select all

I should schedule several rest periods throughout the day I should notify my provider if my temperature is higher than 101 F

Client has anemia and prescription for an oral iron. Which statement by client indicates understanding?

I will eat more high fiber foods.

Nurse's Note: Nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching. Select all that apply.

I will need to do breathing exercises every 1 to 2 hours after the surgery. I will be sure to ask for pain medication before my knee starts to hurt too bad. I will probably be going home with a walker.

Infection prevention to client who has AIDS. Which statement indicates understanding?

I will no longer floss my teeth after brushing my teeth.

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

I will refer you to community resources that can provide support.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period.

Stage II Lyme disease. Which statement reflects understanding?

Joints ache be cause I have lyme disease

Sealed radiation implant for cervical cancer. Which intervention should nurse include in plan of care?

Keep a lead lined container in client's room.

Nurse caring for older client who has dementia and requires acute care for respiratory infection. Client is agitated and attempting to remove IV

Keep client occupied with a manual activity.

Admin RBC's to client. Which assessment finding indicates hemolytic transfusion reaction?

Low back pain and apprehension

Nurse is assessing a client who has diabetes insipidus. Which finding should nurse expect?

Low urine specific gravity

Performing assessment on the client, specify if finding is consistent with appendicitis, diverticular disease, or Crohn's

Nausea: appendicitis/diverticular/Crohns' Diarrhea: Crohn's Blood in stool: diverticular/Crohn's Pain in LRQ: appendicitis/Crohn's

Planning care for the client who has peritonitis and Crohn's disease. Click to specify if each potential prescription is anticipated or contraindicated for the client.

Obtain vital signs every hour: indicated Obtain blood cultures: indicated Administer a hypotonic IV solution: contraindicated Insert a nasogastric tube: Indicated

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which finding should the nurse identify as priority

Report of sore throat

Vitals: emphysema/asthma/pneumonia

Respiratory rate: emphysema/asthama/pneumonia Heart rate: emphysema/pneumonia ABG results: emphysema/pneumonia Breath sounds: emphysema/asthma/pneumonia Cough: emphysema/asthma/pneumonia Temperature: pneumonia

Hemodialysis. Which finding report to provider?

Restlessness

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Scan the bladder with a portable ultrasound.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

Scan the environment by turning your head from side to side.

A nurse is providing follow up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following lab values is amanifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate

Nurse's Note: Reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider?

Serum creatinine - this medication is nephrotoxic.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted in the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate.

A nurse is providing discharge instructions to a client who has active TB. Which of the following information should the nurse include in the instructions?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures

A nurse is caring for a client who is receiving mechanical bentilation via a trach. The nurse whould recognize that which of the following complications is associated with long term mechanical ventilation?

Stress ulcers

A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately?

Stridor

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?

Temperature 102

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Warfarin

Transfuse RBC anticipated vs contraindicated

Trandelenberg position: contraindicated Prepare client for chest tube: anticipated Cover the client with a cooling blanket: contraindicated Initiate NPO: anticipated

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of MI?

Troponin I 8 ng/mL

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips.

A nurse is reviewing the lab results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

WBC count 2,000

A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Walk for 30 min four times per week

Nurse's Note: Select the 3 findings that require follow up by the nurse:

Wound drainage Pain level Oxygen Saturation

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy Which of the following instructions should the nurse include?

You will need to stay in bed during each treatment session.

Pancreatitis as evidence by

amylase and lipase