NRSG 121 ATI

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a life-threatening situation. Rational: Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?

Speak directly to the client in a normal, clear voice. Rational:The nurse is correct to speak directly and normally for the client to hear what is spoken.

A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.)

"I can take this medication with or without food." is correct. Rationale: Food does not affect the absorption of ranitidine. "I will eat five small meals each day" is correct. Rationale:The client should eat 5 to 6 small meals each day to enhance the therapeutic effects of ranitidine.

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include?

"Report swelling of eyelids after dosage." Rational:The client should report swelling of eyelids and lips to provider, which can indicate an allergic reaction to this medication.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty stools Rational:Chronic cholecystitis occurs following several bouts of acute cholecystitis. The repeated episodes of inflammation result in a fibrotic and contracted gallbladder. Because of inflammation in the gallbladder, bile needed to absorb fat and fat-soluble vitamins is unable to enter the bowel, resulting in steatorrhea (fatty stools).

a nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500mL of blood. Which of the following actions is the nurses priority?

Increase the clients IV fluid rate Rational: when using urgent vs. nonurgent approach to client care, the nurse should. Determine that the priority action is to increase the clients IV fluid rate. Providing the fluid to the client will restore circulating volume and increase blood pressure

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?

Minimize environmental stimuli. Rational:A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights,

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?

Monitor sensory perception of the lower extremities. Rational:The nurse should perform neurologic assessments focusing on sensory perception of the lower extremities every 4 hr. Any decrease in sensation by the client requires immediate notification of the provider,

A nurse is assessing a client who is admitted from the PACU following a abdominal hysterectomy. Which of the following assessments is the nurses priority?

Oxygen saturation Rational: the priority action the nurse take when using airway, breathing, circulation approach the client care,is to assess the clients oxygen saturation to determine adequate gas exchange

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

Oral contraceptive use, Immobility. Rational:Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives. Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation.

A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?

Reduced joint. Rationale: Rheumatoid arthritis in autoimmune disease in which the cartilage and bone of the joints are destroyed resulting in increased pain and a limited range of motion. The nurse should instruct the client that rest reduces stress on the joints and can be an effective intervention for relieving pain associated with rheumatoid arthritis.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values Rationale: The greatest risk to this client is injury from the impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea,

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which fo the following findings should the nurse identify as a safety risk?

Scatter rugs present in the kitchen Rational: scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision

A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.)

Tingling in the arms Shoulder pain Stiff neck. rational:Tingling in the arms is correct. Numbness and tingling in the upper extremities are common manifestations of a herniated cervical intervertebral disc. Shoulder pain is correct. Shoulder pain, particularly on the top of the shoulders, is a common manifestation of a herniated cervical intervertebral disc. Stiff neck correct. Pain and stiffness in the neck are common manifestations of a herniated cervical intervertebral disc.

A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vein thrombosis (DVT)?

Unilateral leg edema Rational:Unilateral edema is a manifestation of DVT.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

place the client in a high fowlers position Rationale: The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority-setting framework, the nurse's initial action should be to place the client in high fowlers positions to assist in providing an immediate reduction in blood pressure and intracranial pressure.

A nurse in a clinic is caring for a client requiring a hysterectomy who states that she has decided to delay having this surgery for several months. Which of the following statements should the nurse make?

"Can you elaborate on your reasons for delaying the surgery" Rational:This is an appropriate statement that provides a general lead for the client and facilitates client communication,

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

"You will need to remove all jewelry before the test." Rationale: The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density.

the following responses should the nurse make? A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of

"Can you tell me more about this concern?" Rational:encourage the client to Fears about anesthesia are fairly common, and often stem from past communicate more about her fear so the nurse can intervene effectively experiences of the client or others and from the fear of a loss of control. This response will

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

"Eating yogurt can help decrease the amount of gas that I have." Rational:The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

Both are inflammatory Rational:The nurse should inform the client that both disease processes are an inflammatory process of the gastrointestinal tract.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia Rational:The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine Rational:Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.

A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?

Isosorbide Rational:Clients who are on nitrates including isosorbide and nitroglycerin preparations cannot take sildenafil, because of the serious medication interaction. There is the possibility of sudden death due to hypotension.

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decreases pancreatic secretions.

A nurse in a providers office is reviewing the laboratory for. A client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

Platelet count of 60,000 Rational: this platelet count is below the expected range. A low platelet count places the client at risk of bleeding, therefore, the nurse should follow upon this finding

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

The client faces the direction of movement when sliding an object across the floor. Rational:Sliding an object across the floor rather than lifting prevents strain on the lower back muscles. Facing the direction of movement prevents twisting his back,

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

"I need something for the pain in my eye. I can't stand it." Rational:Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

"I will be certain to take enteric-coated medications." Rational:This is not an appropriate statement and indicates a need for additional teaching. Enteric-coated medications should be avoided to reduce the risk of blockage caused by the coating.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

"Implement a schedule to include periods of rest." Rational:The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include?

"Lie on your right side when sleeping." Rational:The nurse should instruct the client to lie on the right side when sleeping to prevent nighttime reflux.

A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include?

"Sit upright or stand for at least 30 minutes after taking this medication. Rational: The nurse should instruct the client to sit or stand for 30 minutes after administration of this medication to reduce prolonged contact of the medication with the esophageal mucosa that can cause esophagitis.

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

"Store condoms in the refrigerator when not in use." Rationale: The client should store unused condoms in a cool, dry place, such as a bedroom drawer, when not in use.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

Avoid foods prepared with tap water. Rational:To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water.

A nurse is planning care for a client who has a decreased level of consciousness. The client I receiving continuous enteral feeding via a gastroscope tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe clients respiratory status B. Elevate the head of the clients bed 30 to 45 C. Monitor intake and output every 8 hours D. Check residual volume every 4 to 6 hours

Elevate the head of the client bed 30 to 45 Rational: a client who has a decreased level of consciousness and an inability to swallow is a risk factor for aspiration. Lying down also increases the risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration

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 in intracranial pressure (ICP)? (Select all that apply.)

Headache, Slurred speech, Pupillary changes , Disorientation Rational:Headache is correct. A client who has increasing ICP might manifest a headache Slurred speech is correct. A client who has increasing ICP might manifest slurred speech. Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes. Disorientation is correct. A client who has increasing ICP might display disorientation or confusion.

A nurse is assessing a client who reports numbness and pain in his right palm. Index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpel tunnel syndrome. Which of the following tests should the nurse request the the client preform? A.hold the right arm straight B.hold the wrist at a 90. Degree angle C.flex the right arm at the elbow D.extended the right arm upward

Hold the wrist at a 90 degree angel Rational: carpal tunnel syndrome is the Compression of the. Median nerve at the wrist. The. Condition is common in people who preform repetitive motions of the hand and wrist, such as typing. Tapping the median nerve at the wrist cause pain to shoot from the writ to the hand, and ending the wrist at a 90 degree flextime will usually result in numbness, tingling, or weakness

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the follwoing changes in the assessment should indicate to the nurse that the client could be developing a seroius complication?

Increased respiratory rate from 18 to 44/min

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

Sudden abdominal pain Rational: Classic indications of gastrointestinal perforation include sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.

A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?

Systolic blood pressure changed from 140 mm Hg to 120 mm Hg rational:Spinal anesthesia causes vasodilation and if the blood pressure remains more than 10 mm Hg below the client's baseline, there is a potential for shock. The nurse should notify the provider.

A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching?

"I can use either heat or ice to help relieve the discomfort." Rational:The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation.

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

"Til apply ice to my ankle today and tomorrow." Rationale: The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hr after the injury

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2.5 ml Rational: Ratio and Proportion STEP 1: What is the unit of measurement the nurse should calculate? ml. STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 20 mg STEP 3: What is the dose available? Dose available Have 40 mng STEP 4: Should the nurse convert the units of measurement? No STEP 5: 40 mg/5 ml - 20 mg/X ml X= 2.5

A nurse is preparing to instill 840 ml of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver 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.)

35 mL/hr STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 840 ml STEP 3: What is the total infusion time? 24 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 840 mL/24 hr X mL/hr X- 35 mL/hr

A nurse is reviewing the laboratory data of a client who has acute pancreatitis, The nurse should expect to find an elevation of which of following values?

Amylase Ational:Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body, it is produced by the pantreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water Rational: Clients who have myasthenia gravis, an autoimmune disorder, have weakness of the muscles of the face and throat, which increases the risk for aspiration. The nurse should check the client's ability to swallow before administering oral medication.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice Rational: Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Determine what the client knows about the surgery. Rational:The first step in planning preoperative care is to identify the client's learning needs. The nurse does this procedure by determining he clients past experiences with surgery, has current knowledge about the scheduled procedure, and identifying his expectations and fears.

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

Elevated blood urea nitrogen (BUN) Rational:As the body digests blood, BUN rises. An elevated BUN is an indication of Gl bleeding.

A nurse is planning care for a client who has a decreased level of consciousness. The client I receiving continuous enteral feeding via a gastroscope tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Enoxaparin subcutaneous Rational:Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for DVT prophylaxis following orthopedic surgery.

A nurse is planning care for a client who has diverticulitis, Which the of following menu selections should the nurse include in the plan?

Grilled chicken breast with white rice Rational:Both of these items are low in fiber which is advised during the inflammation of diverticulitis. In the presence of diverticulosis, a high-fiber diet is indicated.

A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which os the following findings indicates the client is experiencing a complication of the anesthesia?

Headache Rational: when spinal fluid is lost through a leak at the puncture site around the spinal column, a severe headache can occur, which may last several days.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes. Rationale: The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture, Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

A nurse in the emergency department is caring who. Has a compression fracture of a spinal vertebrae. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family, which of the following actions should the nurse anticipate the neurosurgeon taking?

Invoking implied consent Rational: the client is unable to sign a consent form because he is sedated from the morphine. The neurosurgeon has the legal right to invoke implied consent and proceed with the surgery if it is determined an emergency

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition?

Knuckle deformity Rational: joint deformity is a late manifestation of RA

A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?.

Leuprolide Rational:Leuprolide treats cancer of the prostate hormonally. It antagonizes the androgens that androgen-dependent neoplasms require.

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?

Localized erythema Rational:Swelling and localized erythema are manifestations of acute osteomyelitis.

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)

Muscle distortion Pain behind the ear Impaired taste Rational:Muscle distortion is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes muscle distortion that gives the affected side a drooping appearance. Pain behind the ear is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes pain behind the ear, in the face, and in the eye on the affected side. Impaired taste is correct. Bell's palsy, which is facial paralysis that stems from one-sided inflammation of cranial nerve VII, causes impaired taste, as well as difficulties with speech and eating.

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?

Pitting edema around the stump dressing Rational: If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.

A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?

Poor Rationale: At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages.