ATI practice Q week 3 and 4

a nurse is performing DC teaching for a client who has seizures and a new prescription for phenytoin. which of the following statements by the client indicates a need for further teaching? "I will notify my doctor before taking any other medications." "I have made an appointment to see my dentist next week." "I know that I cannot switch brands of this medication." "I'll be glad when I can stop taking this medicine."

"I'll be glad when I can stop taking this medicine."

a nurse is talkign with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? "I wish I didn't have to attach the electrodes to my skin." "It's unfortunate that I have to be in the hospital for this treatment." "I'll need to shave the hair off the skin where I place the electrodes." "I hope I don't have to take as many pain pills."

"It's unfortunate that I have to be in the hospital for this treatment."

a nurse is assisting with obtaining an ECG for a client who has atrial fib. Which of the following actions should the nurse take? SATA Keep the client NPO after midnight. Inspect the electrode pads. Wash the skin with plain water before placing the electrodes. Instruct the client not talk during the test. Administer an analgesic prior to the procedure.

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

a nurse is reviewing the EKG strop 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? Abnormally prominent U wave Elevated ST segment Wide QRS Inverted P wave

Abnormally prominent U wave Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

a nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take? Administer the medication at 100 mg/min. Administer a saline solution after injection. Hold the injection if seizure activity is present. Dilute the medication with dextrose 5% in water.

Administer a saline solution after injection.

a nurse is caring for a child who has a suspected dx of bacterial meningitis. Which of the following actions is the nurse's priority? Administer antibiotics when available. Reduce environmental stimuli. Document intake and output. Maintain seizure precautions.

Administer antibiotics when available.

a nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? Ventricular depolarization. Slow repolarization of ventricular Purkinje fibers. Atrial depolarization. Early ventricular repolarization.

Atrial depolarization. The P wave reflects atrial depolarization, typically initiated in the sinoatrial node. The QRS complex reflects ventricular depolarization. A U wave appears when there is slow repolarization of ventricular Purkinje fibers. The ST segment reflects early ventricular repolarization.

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? First-degree AV block Atrial fibrillation Sinus bradycardia Sinus tachycardia

Atrial fibrillation 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 caring for an adolescent who was brought to the emergency department (ED). The nurse should determine the assessment findings are consistent with which of the following disease processes? CSF analysis results Reaction to pupil assessment Location of pain GI manifestations Neck range of motion Mood Body temperature

Bacterial Meningitis - Mood, Location of pain, Body temperature, GI manifestations, Reaction to pupil assessment, Neck range of motion, CSF analysis results Encephalitis - Location of pain, Body temperature, GI manifestations, Reaction to pupil assessment,Neck range of motion

a nurse is assessing the resp pattern of an older adult client who is receiving end of life care. which of the following assessments findings should the nurse identify as cheyne stokes repsirations? Breathing ranging from very deep to very shallow with periods of apnea. Shallow to normal breaths alternating with periods of apnea. Rapid respirations that are unusually deep and regular. An inability to breathe without dyspnea unless sitting upright.

Breathing ranging from very deep to very shallow with periods of apnea

**a nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. which of the following condition is the client displaying? Kernig's sign Nuchal rigidity Brudzinski's sign Bradykinesia

Brudzinski's sign

a nurse is assessing a clients CN as part of a neurological examination. Which of the following actions should the nurse take to assess CN 3? Testing visual acuity Observing for facial symmetry Eliciting the gag reflex Checking the pupillary response to light

Checking the pupillary response to light

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

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

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

Defibrillation 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 caring for a client who has pericarditis and reports feeling a new onset of palpitations and SOB. Which of the following assessments should indicate to the nurse that the client may have developed atrial fib? Different blood pressures in the upper limbs. Different apical and radial pulses. Differences between oral and axillary temperatures. Differences in upper and lower lung sounds.

Different apical and radial pulses.

a nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? Defibrillation Elective cardioversion CPR Radiofrequency catheter ablation

Elective cardioversion

a nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should nurse remove first? Gown Gloves Face shield Mask

Gloves

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? Whisper in one of the client's ears while occluding the other. Observe for facial symmetry while the client smiles. Have the client identify specific smells. Check the client's visual acuity using a Snellen chart.

Have the client identify specific smells.

a nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following mani should indicate to the nurse the client is experiencing an increase in ICP? SATA Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache Slurred speech Pupillary changes Disorientation

a nurse is preparing to administer verapamil by IV bolus to a client who is receiving cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? Hyperthermia Hypotension Ototoxicity Muscle pain

Hypotension

a nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Tachycardia Irritability Tinnitus

Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

a nurse is providing teaching to a client who is post op following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effect of medications should the nurse identify as most important for the client's recovery? It decreases the client's level of anxiety. It facilitates the client's deep breathing. It enhances the client's ability to sleep. It reduces the client's blood pressure.

It facilitates the client's deep breathing.

A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect? Lightheadedness Elevated temperature Anxiety Fluid volume deficit

Lightheadedness

a nurse is caring for a client who has atrial fib and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? Offer the client a light snack. Measure the client's blood pressure. Measure the client's apical pulse. Weigh the client.

Measure the client's apical pulse.

a nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take? Place the client in protective isolation. Minimize environmental stimuli. Elevate the head of the client's bed 45°. Limit the client's ambulation to once a day.

Minimize environmental stimuli.

a nurse is reviewing lab results of a client who has A.Fib and is taking warfarin. For which of the following results should the nurse notify the provider? PT 45 seconds Hgb 16 g/dL Hct 44% Platelets 190,000/mm3

PT 45 seconds The expected reference range for PT is 11 to 12.5 seconds. The expected reference range for Hgb in males is 14 to 18 g/dL and in females is 12 to 16 g/dL. he expected reference range for Hct in males is 42% to 52% and in females is 37% to 47%. expected reference range for platelets is 150,000 to 400,000/mm3.

a nurse is caring for a client who has right sided acoustic neuroma resulting in impairment of CN 9 and 10. which of the following actions should the nurse take? Place suction equipment at the client's bedside. Apply an eye patch to the client's right eye. Avoid the use of warm water to wash the client's face. Provide range-of-motion exercises to the client's neck and shoulders.

Place suction equipment at the client's bedside.

a nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? Insert a tongue blade in the client's mouth. Place the client on his side. Hold the client's arms and legs from moving. Place the client back in bed.

Place the client on his side.

a nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. which of the following interventions should the nurse include? SATA Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside.

a nurse is teaching a client who has a new dx of a.fib. The nurse should instruct the client to monitor for which of the following complications? Bradycardia Pulmonary embolism Peripheral vascular disease Hypertension

Pulmonary embolism

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence? Overflow incontinence Urge incontinence Reflex incontinence Stress incontinence

Reflex incontinence

a nurse is assessing a client who has meningitis. which of the following findings should the nurse expect? Severe headache Bradycardia Blurred vision Oriented to person, place, and year

Severe headache

a nurse in the ED is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 ml/hr. Which of the following is an appropriate action by the nurse? Slow the rate to 20 mL/hr. Continue the rate at 125 mL/hr. Slow the rate to 50 mL/hr. Increase the rate to 250 mL/hr.

Slow the rate to 50 mL/hr.

a nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? Edematous bruise on forehead Small drops of clear fluid in left ear Pupils are 4 mm and reactive to light Glasgow Coma Scale (GCS) score of 12

Small drops of clear fluid in left ear

a nurse is caring for a client who has a mental illness. which of the following actions by the nurse demonstrates the ethical concept of autonomy? Encouraging client feedback about satisfaction with the facility experience Explaining unit rules and policies regarding unacceptable behaviors Supporting the client's wish to refuse prescribed medications Making sure the client understands expectations for client participation

Supporting the client's wish to refuse prescribed medications

a nurse is in a client's room when the client's begin having a tonic clonic seizure. which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side.

a nuurse is caring for a client who has increased ICP following a closed head injury. Which of the following actions should the nurse take? Instruct the client to cough and deep breathe. Place the client in a supine position. Place a warming blanket on the client. Use log rolling to reposition the client.

Use log rolling to reposition the client.

a nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide? Phenytoin turns urine blue. Alcohol increases the chance of phenytoin toxicity. Avoid flossing the teeth to prevent gum irritation. Take an antacid with the medication if indigestion occurs.

Alcohol increases the chance of phenytoin toxicity.

a nurse is assessing a clients CN. Which of the following methods should the nurse use to assess CN 2? Ask the client to read a Snellen chart. Listen to the client's speech. Ask the client to identify scented aromas. Ask the client to clench his teeth.

Ask the client to read a Snellen chart.

a nurse is implementing precautions for a client who has a cerebral aneurysm. Which fo the following nursing interventions should the nurse implement? Allow bathroom privileges. Encourage exhaling through mouth during defecation. Allow natural sunlight in the room. Encourage visitation from family and friends.

Encourage exhaling through mouth during defecation.

a nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase ICP? SATA Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache Slurred speech Pupillary changes Disorientation

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? Asthma Aortic valve regurgitation Heart failure Aortic stenosis

Heart failure

a nurse in an ED is caring for a client who had a seizure and become unresposive after stating she had a sudden, severe headache and vomiting. the clients vs: BP 198/110, pulse 82, resp 24, temp 100.8. which of the following neurological disorder should nurse suspect? Transient ischemic attack (TIA) Hemorrhagic stroke Thrombotic stroke Embolic stroke

Hemorrhagic stroke

a nurse is assessing a client who has atrial fib. Which of the following pulse characteristics should the nurse expect? Slow Not palpable Irregular Bounding

Irregular

a nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing ICP. which of the following medications should the nurse plan to administer? Albumin 25% Dextran 70 Hydroxyethyl glucose Mannitol 25%

Mannitol 25%

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? Serum cardiac enzyme levels MRI of the chest Physical therapy Low-sodium diet

MRI of the chest A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.

a nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take? Elevate the head of bed to 45°. Maintain the client on absolute bed rest. Administer a cleansing enema. Place the client in a room near the nurses' station.

Maintain the client on absolute bed rest. The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.

a nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? Gradual onset of several hours Manifestations preceded by a severe headache Maintains consciousness History of neurologic deficits lasting less than 1 hr

Manifestations preceded by a severe headache

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII? Have the client identify specific smells. Observe for facial symmetry while the client smiles. Check the client's visual acuity using a Snellen chart. Whisper in one of the client's ears while occluding the other.

Observe for facial symmetry while the client smiles.

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI? Have the client identify specific smells. Whisper in one of the client's ears while occluding the other. Observe for the ability of the client to turn their head side to side. Check the client's visual acuity using a Snellen chart.

Observe for the ability of the client to turn their head side to side.

a nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care? Obtain IV access. Keep the lights on when the client is sleeping. Place the client's bed in the high position. Keep a padded tongue blade available at the client's bedside.

Obtain IV access.

a nurse is caring for a client who has quadriplegia from a SCI and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? Administer a nitrate antihypertensive. Assess the client for bladder distention. Place the client in a high-Fowler's position. Obtain the client's heart rate.

Place the client in a high-Fowler's position.

a nurse is caring for a client who has a SCI and suspects the client is developing autonomic dysreflexia. which of the following actions should the nurse take first? Check the client for a fecal impaction. Examine the client for areas of skin breakdown. Check the client's bladder for distention. Place the client in a sitting position.

Place the client in a sitting position.

a nurse is caring for a client who has a central venous cath and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clams the cath immediately. What other action should the nurse take at this time? Prepare for chest tube insertion. Place the client on his left side in Trendelenburg position. Remove the catheter. Replace the infusion system.

Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

a nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? Pushes the painful stimulus away. Extends her body toward the painful stimulus. Shows no reaction to the painful stimulus. Flexes the upper and extends the lower extremities in response to the painful stimulus.

Pushes the painful stimulus away

a nurse is caring for a client who has meningitis, a temp of 103.5 and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must be carefully be observed for which of the following complications? Dehydration Seizures Burns Shivering

Shivering

a nurse is caring for a client who requires total parenteral nutrition (TPN). which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly? Turn the client on his left side. Sit the client upright. Prepare to add insulin to the TPN infusion. Stop the TPN infusion.

Sit the client upright.

a nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? Systolic blood pressure is increased. Cardiac output is reduced. Apical heart rate is increased. Urine output is reduced.

Systolic blood pressure is increased

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

The client experiences sudden weakness of one arm and leg. Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse's priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.

a nurse is receiving a transfer report for a client who has a head injury. the client has a GSC score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. which of the following is an appropriate conclusion based on this data? The client can follow simple motor commands. The client is unable to make vocal sound. The client is unconscious. The client opens his eyes when spoken to.

The client opens his eyes when spoken to.

a nurse is caring for a client who has a T4 Spinal cord injury. Which of the following client findings should the nurse identify as a indication the client is at risk for experiencing autonomic dysreflexia? The client states having a severe headache. The client's bladder becomes distended. The client's blood pressure becomes elevated. The client states having nasal congestion.

The client's bladder becomes distended.

a nurse is preparing to administer dabigatran to a client who has atrial fib. The nurse should explain that the purpose of this medication is which of the following? To convert atrial fibrillation to sinus rhythm. To dissolve clots in the bloodstream. To slow the response of the ventricles to the fast atrial impulses. To reduce the risk of stroke in clients who have atrial fibrillation.

To reduce the risk of stroke in clients who have atrial fibrillation. Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation.

a nurse is caring for a client who is on warfarin therapy for atrial fibrillation. the client's INR is 5.2. which of the following medications should the nurse prepare to administer? Epinephrine Atropine Protamine Vitamin K

Vitamin K

a nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased ICP as indicated by which of the following findings? Nuchal rigidity Pupils reactive to light Widened pulse pressure Elevated temperature

Widened pulse pressure

A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. Temperature 36.6° C (97.8° F)Apical pulse 42/min Respiratory rate 26/minBlood pressure 104/68 mm HgOxygen saturation 94% on room air The nurse should monitor the client for Select... and Select... following permanent pacemaker placement.

Incisional site bleeding & Bradycardia

a nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of CN 3? Instruct the client to look up and down without moving his head. Observe the client's ability to smile and frown. Have the client stand with eyes his closed and touch his nose. Ask the client to shrug his shoulders against passive resistance.

Instruct the client to look up and down without moving his head.

a nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? PR interval QT interval ST segment QRS complex

QT interval

A nurse is caring for a client who has a seizure disorder. SATA Administer supplemental oxygen to the client. Place a tongue depressor in the client's mouth. Turn the client to the side. Time the duration of the seizure. Restrain the client.

Administer supplemental oxygen to the client. Turn the client to the side. Time the duration of the seizure.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII? Whisper in one of the client's ears while occluding the other. Observe for the ability of the client to turn their head side to side. Have the client identify specific smells. Ask the client to stick out their tongue and observe if it is midline.

Ask the client to stick out their tongue and observe if it is midline.

a nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Epinephrine Magnesium Atropine Sodium bicarbonate

Atropine

a nurse is caring for a client who has ICP reading 40 mm hg. Which of the following findings should the nurse identify as a late sign of ICP? SATA Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech

Bradycardia Nonreactive dilated pupils

a nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? Pacemaker spikes after each QRS complex Pacemaker spikes before each P wave Pacemaker spikes before each QRS complex Pacemaker spikes with each T wave

Pacemaker spikes before each QRS complex. The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.