F2 ATI Chapter Questions Exam 2

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading of the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. "I should wash my hands after blowing my nose to prevent spreading of the virus."

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates that the teaching has been effective? A. "Metabolic acidosis can occur due to DKA." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer."

A. "Metabolic acidosis can occur due to DKA."

A nurse providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (SATA) A. "Take your heart medication with a sip of water before surgery." B. "Splint the abdominal incision with a pillow when coughing and deep breathing." C. "Bed rest is recommended for the first 48 hr." D. "Antiembolism stockings are applied before surgery." E. "You may eat solid food up to 4 hours before surgery."

A. "Take your heart medication with a sip of water before surgery." B. "Splint the abdominal incision with a pillow when coughing and deep breathing." D. "Antiembolism stockings are applied before surgery."

A nurse is reviewing the health records of several clients in the PACU to identify risk factors that can lead to post-op complications. Which of the following clients are at risk for complications? (SATA) A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client who takes warfarin daily D. A client who has heart failure E. A client who has a BMI of 26

A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client who takes warfarin daily D. A client who has heart failure

A nurse is caring for a client who reports nausea and vomiting 2 days post-op following a hysterectomy. Which of the following actions should the nurse report first? A. Assess bowel sounds B. Administer antiemetic medication C. Restart prescribed IV fluids D. Insert a prescribed NGT

A. Assess bowel sounds

A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess oxygen saturation B. Measure blood pressure C. Palpate pulse rate D. Check temperature

A. Assess oxygen saturation

A nurse is monitoring a group of clients for increased risk of pneumonia. Which of the following clients should the nurse expect to be at risk? (SATA) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is post-op and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A nurse is reviewing ABG lab results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mmHg, HCO3 22 mmHg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (SATA) A. Dyspnea B. Localized bloody drainage C. Fever D. Hypotension E. Report of pain at the puncture site

A. Dyspnea C. Fever D. Hypotension

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Encourage use of the incentive spirometer Q2hr B. Instruct the client to splint the incision when coughing and deep breathing C. Reposition the client Q2hr D. Administer antibiotic therapy E. Assist with early ambulation

A. Encourage use of the incentive spirometer Q2hr B. Instruct the client to splint the incision when coughing and deep breathing C. Reposition the client Q2hr E. Assist with early ambulation

A nurse caring for a client who is scheduled for an exploratory laparotomy. The clients temperature is 102.2 F orally. Which of the following actions should the nurse take? A. Inform the surgeon of the elevated temperature B. Transfer the client to the preoperative unit C. Apply ice packs to the groin D. Encourage the client to increase intake of clear liquids

A. Inform the surgeon of the elevated temperature

A nurse is caring for a climate who develops malignant hyperthermia. Which of the following actions should the nurse take? (SATA) A. Infuse iced IV fluids B. Provide 100% oxygen C. Place the client on a cooling blanket D. Treat the complication while continuing surgery E. Administer IV dantrolene

A. Infuse iced IV fluids B. Provide 100% oxygen C. Place the client on a cooling blanket E. Administer IV dantrolene

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize hi, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is a nursing priority? A. Obtain baseline VS and O2 saturation B. Obtain a sputum culture C. Obtain a complete history from the client D. Provide a pneumococcal vaccine

A. Obtain baseline VS and O2 saturation

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the clients room? (SATA) A. Oxygen equipment B. Incentive spirometer C. Pulse ox D. Sterile dressing E. Suture removal kit

A. Oxygen equipment C. Pulse ox D. Sterile dressing

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Postion the client in an upright position, leaning over the bedside table B. Explain the procedure C. Obtain ABGs D. Administer benzocaine spray

A. Postion the client in an upright position, leaning over the bedside table

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the clients respiratory muscles should the nurse include in the plan of care? (SATA) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation

A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (SATA) A. Urine output less than 25 mL/hr B. Hematocrit 48% C. BUN 24 mg/dL D. Tenting of the skin over the sternum E. Apical pulse rate 62/min

A. Urine output less than 25 mL/hr B. Hematocrit 48% C. BUN 24 mg/dL D. Tenting of the skin over the sternum

A nurse is caring for a client who was in a MVA. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.06; PaO2 86 mmHg; PaCO2 52 mmHg; HCO3 24 mEq/L B. pH 7.42; PaO2 100 mmHg; PaCO2 38 mmHg; HCO3 23 mEq/L C. pH 6.98; PaO2 100 mmHg; PaCO2 30 mmHg; HCO3 18 mEq/L D. pH 7.58; PaO2 96 mmHg; PaCO2 38 mmHg; HCO3 29 mEq/L

A. pH 7.06; PaO2 86 mmHg; PaCO2 52 mmHg; HCO3 24 mEq/L

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 antagonist

D. Beta2 antagonist

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can reduce my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

B. "I take this medication to prevent asthma attacks."

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

B. "It allows preset pressure delivered during spontaneous ventilation."

A nurse is caring fro a client who has pneumonia. Assessment findings include temperature 100 F, respirations 30/min, BP 130/76, HR 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics B. Administer O2 therapy C. Perform a sputum culture D. Administer an antipyretic medication to promote client comfort

B. Administer O2 therapy C. Perform a sputum culture A. Administer antibioticsD. Administer an antipyretic medication to promote client comfort

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor serum creatinine levels B. Provide airway support C. Turn the client to the right side D. Administer 0.9% sodium chloride 500 mL IV bolus

B. Provide airway support

A nurse is assessing a client who has a Hx of asthma. Which of the following factors should the nurse identify as a risk factor for asthma? A. Gender B. Environmental allergies C. Alcohol use D. Race

B. Environmental allergies

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (SATA) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated BP

B. Pale skin E. Elevated BP

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

D. Bronchospasms

A nurse is caring for a client who has dyspnea and will receive O2 continuously. Which of the following O2 devices should the nurse use to deliver a precise amount of O2 to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. Venturi mask

A nurse in the ED is caring for client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (SATA) A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucus membranes E. Premature ventricular complexes (PVCs)

B. Wheezing C. Retraction of sternal muscles E. Premature ventricular complexes (PVCs)

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? A. "I will decrease my fluid intake while taking this medication." B. "I will expect to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication."

C. "I will take my medication with meals."

A nurse is assessing a client lab values before surgery. Which of the following results should the nurse report to the provider? (SATA) A. Potassium 3.9 mEq/L B. Sodium 145 mEq/L C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850

C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (SATA) A. Explain to the client the purpose of having the procedure B. Inform the client of risks to having the procedure C. Ensure the client understands information about the procedure D. Witness the client signing the informed consent form E. Determine if the client is capable of understanding the reason for the procedure

C. Ensure the client understands information about the procedure D. Witness the client signing the informed consent form E. Determine if the client is capable of understanding the reason for the procedure

A nurse administered midazolam IV bolus to a client before a procedure. His BP is 86/40 mmHg and his pulse is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil D. Atropine

C. Flumazenil

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. Decrease the clients fluid intake B. Apply pressure to the puncture site C. Place the HOB flat D. Instruct the client to lie prone

C. Place the HOB flat

A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal blood pressure 104/72 mmHg, HR 116/min with regular rhythm, and RR 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68; PaO2 96 mmHg; PaCO2 38 mmHg; HCO3 28 mEq/L B. pH 7.48; PaO2 100 mmHg; PaCO2 28 mmHg; HCO3 23 mEq/L C. pH 6.98; PaO2 100 mmHg; PaCO2 33 mmHg; HCO3 18 mEq/L D. pH 7.58; PaO2 96 mmHg; PaCO2 38 mmHg; HCO3 29 mEq/L

C. pH 6.98; PaO2 100 mmHg; PaCO2 33 mmHg; HCO3 18 mEq/L

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint it self-extubation is attempted B. Monitor ventilator settings Q8hr C. Document tube placement in centimeters at the angle of jaw D. Assess breath sounds every 1 to 2 hours

D. Assess breath sounds every 1 to 2 hours

A nurse is obtaining ABGs for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas

D. Palpation of the orbital areas

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses B. Apply a warm blanket C. Assess dressings D. Place the client in a lateral position

D. Place the client in a lateral position

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. Encourage the client to void after preoperative medication administration B. Administer antibiotics 2 hr prior to surgical incision C. Remove hair using a manual razor D. Remove nail polish from fingers and toes

D. Remove nail polish from fingers and toes

A nurse is assessing a client who has pancreatitis. The clients ABGs reveal metabolic acidosis. Which of the following are expected findings? (SATA) A. Tachycardia B. Hypertension C. Bounding pulses D. Hyperreflexia E. Dysrhythmia F. Tachypnea

E. Dysrhythmia F. Tachypnea