MS ATI B
A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? Painless ulcerations on the ankles Hair loss on the lower legs No extremity pain when resting Rubor with elevation of the extremity
Hair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? Elevated blood pressure Dehydration Stress ulcers Hypernatremia
Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? Suction machine Wire cutters Padded clamp Communication board
Suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Obtain ABGs. Administer propofol to the client. Instruct the client to allow the machine to breathe for them. Disconnect the machine and manually ventilate the client.
Instruct the client to allow the machine to breathe for them. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Remove the client's indwelling urinary catheter. Irrigate the indwelling urinary catheter. Clamp the indwelling urinary catheter. Apply traction to the indwelling urinary catheter.
Irrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.
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? Document the client's intake and output. Scan the bladder with a portable ultrasound. Pour warm water over the client's perineum. Perform a straight catheterization.
Scan the bladder with a portable ultrasound. Scan the bladder with a portable ultrasound.
A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?
This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching? Try to walk at least three times per week for exercise. To increase stamina, walk for 5 min after fatigue begins. Take over-the-counter cough medicine for persistent cough. Use a salt substitute to reduce sodium intake.
Try to walk at least three times per week for exercise. The development of a regular exercise routine can improve outcomes in clients who have heart failure.
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? "I should take calcium supplements so the medication will work better in my system." "I am taking this medication to increase my energy level." "This medication can cause my blood pressure to drop." "I will not need to restrict protein in my diet while taking this medication."
"I am taking this medication to increase my energy level." The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.
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? Hydrocodone Bupropion Lactulose Warfarin
Warfarin Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.
A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take.
provided informed consent, administer gentamicin 100 mg IV, and the client's prescribed PO phenytoin
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? "I will take my iron with a glass of milk." "I will take an antacid with my iron." "I will limit my intake of red meat." "I will eat more high-fiber foods."
"I will eat more high-fiber foods." The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? Apply ice to the client's puncture wounds. Initiate corticosteroid therapy for the client. Keep the client's leg above heart level. Administer an opioid analgesic to the client.
Administer an opioid analgesic to the client. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
The nurse is planning care for the client. (For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.)
Anticipated: - Obtain blood cultures. - Obtain vital signs every hour. - Insert a nasogastric tube. Contraindicated: - Administer an intermittent IV bolus of fluid within 1 hour.
A nurse is reviewing the laboratory results of a 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? Potassium 4.8 mEq/L Magnesium 1.7 mEq/L BUN 34 mg/dL Hematocrit 45%
BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Hypotension Tachypnea Nuchal rigidity Bradycardia
Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? Inspect the cast for drainage once every 24 hr. Check that one finger fits between the cast and the leg. Perform neurovascular checks every 2 to 3 hr. Make sure the client has a warm blanket covering the cast.
Check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.
The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
- 12 % weight loss over 2 months - muscle guarding and tenderness in right lower quadrant of abdomen, - abdominal firmness and rigidity, - abdominal pain rate of 8, - hypoactive bowel sounds, - report of anorexia - temperature of 38.5 C (101.4 F)
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity Hypertension Bounding peripheral pulses Hyperglycemia
Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? Bounding pedal pulse Capillary refill less than 2 seconds Pain that increases with passive movement Areas of warmth on the cast
Pain that increases with passive movement The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.
A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? Defibrillate the client's heart. Perform synchronized cardioversion. Begin cardiopulmonary resuscitation. Administer lidocaine IV bolus.
Perform synchronized cardioversion. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.
A 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 1 INR 2.5 aPTT 45 seconds aPTT 90 seconds
INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? Take an antacid before meals and at bedtime. Increase fiber intake to at least 30 g per day. Drink ginger tea daily. Consume no more than 1 L of water per day.
Increase fiber intake to at least 30 g per day. Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? Monitor the client's INR daily. Expel air bubbles when using a prefilled syringe. Inject the medication into the anterolateral abdominal wall. Massage the injection site after administration.
Inject the medication into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? "It is just easier to let my partner administer my insulin." "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." "I'm concerned I won't be able to read my blood sugar level because the screen is so small." "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."
"I used to never worry about my feet. Now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.
A nurse is caring for a client who is scheduled for a right knee arthroplasty. The 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 the breathing exercises every 1 to 2 hours after the surgery" - Rationale: The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. "I will be sure to ask for pain medication before my knee starts to hurt too bad" - Rationale: For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe "I will probably be going home with a walker" - Rationale: It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery.
A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.) "I will pack my abdominal wound with gauze after cleaning it." "I should avoid taking vitamin supplements." "I should alternate taking acetaminophen with my prescribed pain medication." "I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit."
"I will schedule several rest periods throughout the day" and "I will notify my provider if temperature is greater than 101 F.
A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? "I should clean my toothbrush in the dishwasher once a month." "I should eat more fresh fruit and vegetables." "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." "I will take my temperature once a day."
"I will take my temperature once a day." A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.
A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I will wash the ink markings off the radiation area after each treatment." "I will use my hands rather than a washcloth to clean the radiation area." "I will be able to be out in the sun 1 month after my radiation treatments are over." "I will use a heating pad on my neck if it becomes sore during the radiation therapy."
"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I should avoid walking as much as possible." "I should sit down and read for several hours a day." "I will wear clean graduated compression stockings every day." "I will keep my legs level with my body when I sleep at night."
"I will wear clean graduated compression stockings every day." The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? "I will need to take antibiotics for 1 year." "My partner will need to take an antiviral medication." "My joints ache because I have Lyme disease." "I bruise easily because I have Lyme disease."
"My joints ache because I have Lyme disease." Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.
A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? "This measures how much blood my heart is pumping." "This identifies if I have a defective heart valve." "This identifies if the pacemaker cells of my heart are working properly." "This measures the blood circulating to my heart muscle."
"This identifies if the pacemaker cells of my heart are working properly." Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.
A nurse is caring for a client who was just admitted from the emergency department (ED). The client is most likely experiencing (__1__) and (__2__)
1. Acute chest syndrome 2. pneumonia
After reviewing the findings in the client's medical record, the nurse should first address the client's (1) followed by the client's (2)
1. infection 2. pain rating
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
167
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: 1. Administer morphine IV. 2. Ensure the client is NPO. Potential Condition: 1. Cholecystitis Parameters to Monitor: 1. Monitor the color of the client's stools 2. Monitor the client for dark urine.
The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.)
Appendicitis: - pain - temperature - GI concerns Chron's Disease: - stool color - pain location - temperature - GI concerns
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? Shellfish Peanuts Eggs Avocados
Avocados Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? Ginkgo biloba Glucosamine Calcium Vitamin C
Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.
A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? Position tabletop clocks with multi-colored backgrounds throughout the home. Explain how to complete a task while having the client do the task. Place a calendar on the wall with days and weeks included. Create complete outfits and allow the client to select one each day.
Create complete outfits and allow the client to select one each day. The family should place completed outfits on hangers and allow the client to select which one to wear each day.
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? Decreased T cells Increased creatinine clearance Increased eosinophils Decreased viral load
Decreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.
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. Assist the client to start arm exercises 48 hr after surgery. Maintain the right arm in an extended position at the client's side when in bed. Place the client in a supine position for the first 24 hr after surgery.
Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? Nonrebreather mask Venturi mask Simple face mask Partial rebreather mask
Nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? 240 mL (8 oz) of orange juice 1 ampule of 50% dextrose IV bolus NPH insulin 60 units subcutaneous Regular insulin 20 units IV bolus
Regular insulin 20 units IV bolus DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion. Prime the blood administration IV tubing with lactated Ringer's solution. Verify the client's identity by using the client's room number prior to starting the transfusion. Infuse the unit of packed RBCs within 8 hr.
Remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.
A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? Keep the client's personal care items in the bathroom. Keep the overhead lights on in the client's bedroom while the client is sleeping. Remind the client to scan their complete range of vision during ambulation. Secure the client's extension cords under carpeting.
Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? Report of sore throat Report of memory loss Alopecia Mucositis
Report of sore throat When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.
A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? Avoid foods that are high in ascorbic acid. Add oatmeal to the water when taking a tub bath. Urinate every 6 hr. Take daily cranberry supplements.
Take daily cranberry supplements. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.
For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.
Temperature - pneumonia Breath sounds - emphysema, asthma, & pneumonia Respiratory rate - emphysema, asthma, & pneumonia Cough - emphysema, asthma, & pneumonia Heart rate - emphysema and pneumonia ABG results - emphysema and pneumonia
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 a myocardial infarction (MI)? Creatine kinase (CK-MB) 85 units/L High-density lipoprotein (HDL) 65 mg/dL Alanine aminotransferase (ALT) 28 units/L Troponin I 8 ng/mL
Troponin I 8 ng/mL ALT is an enzyme that is found primarily in the liver, although it can also be detected in the kidneys, heart, and skeletal muscle. Increases in this enzyme are associated with injury or disease. However, because the enzyme is not specific to the heart, its use as a diagnostic tool for MI is limited. An ALT value of 28 units/L is within the expected reference range.
