NURS 3664. ATI Prep (Part 1)

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to lie still in bed during my brachytherapy treatment." B. "I will have an implant placed once a month during my brachytherapy treatment." C. "I must stay at least 3 feet away from others between brachytherapy treatments." D. "I should expect some blood in my urine after each brachytherapy treatment."

A. "I need to lie still in bed during my brachytherapy treatment." The nurse should confirm that the client understands the need to remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgment.

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following pieces of information should the nurse include? A. "You might need glasses after the surgery." B. "You may drive home after the procedure." C. "Continue to wear your contact lenses until the day of the surgery." D. "Expect complete healing and clear vision in about a week."

A. "You might need glasses after the surgery." LASIK is a type of refractive laser eye surgery that ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.

A nurse is teaching a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching? A. "You should complete the entire cycle of antibiotic therapy." B. "You should maintain complete bed rest until manifestations decrease." C. "You should drink 1,000 mL of fluid per day." D. "You should avoid using NSAIDs for pain."

A. "You should complete the entire cycle of antibiotic therapy."

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr."

A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure. Incorrect Answers: C. The client will feel a sensation similar to a hot flash when the dye enters the heart. E. Adequate hydration, both IV and oral, is crucial for excreting the contrast medium and reducing the risk of renal toxicity from retaining the dye.

A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? A. Amylase B. Potassium C. Calcium D. Hematocrit

A. Amylase With pancreatitis, laboratory results typically show elevated amylase within 12 to 24 hours. This level remains elevated for 2 to 3 days. A decrease in magnesium is also possible

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. Dry cough A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority? A. Dysrhythmias B. Pink-tinged urine C. Bruising on the flank area D. Stone fragments in the urine

A. Dysrhythmias ESWL is the application of sound, laser, or dry shock wave energies to break a kidney stone into small pieces. The shock waves are initiated during the R wave of the ECG to prevent dysrhythmias. When using the ABC approach to client care, the nurse should determine that dysrhythmias are the priority finding.

A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? A. Fortified milk B. Ripe bananas C. Steamed broccoli D. Green leafy vegetables

A. Fortified milk Fortified milk provides 2.45 mcg of vitamin D, which promotes calcium absorption from the gastrointestinal tract. Adults up to age 70 need 600 international units of vitamin D per day and 800 international units thereafter. Therefore, fortified milk is a good source of vitamin D.

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)

A. Gamma-glutamyl transferase (GGT) The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A. Increased mucus secretion B. Bronchial dilation C. Bradycardia D. Vertigo

A. Increased mucus secretion The nurse should instruct the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take? A. Keep visitors at least 6 feet (1.8 m) away from the client. B. Discard the radioactive material into a biohazard trash bag C. Place soiled linen in a laundry bag outside the client's room D. Keep the door to the client's room open to promote air movement

A. Keep visitors at least 6 feet (1.8 m) away from the client.

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? A. Meperidine B. Amitriptyline C. Gabapentin D. Propranolol

A. Meperidine Opioids are more effective for residual limb pain rather than phantom limb pain. Additionally, meperidine is not recommended for chronic pain because long-term use can cause accumulation of a toxic metabolite.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

A. Prothrombin time A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk of bleeding. In addition to prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear? A. Eustachian tube B. Cochlea C. Perichondrium D. Eardrum

B. Cochlea Ménière's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system.

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure

B. Increased pulmonary congestion Pulmonary congestion occurs due to thickening and narrowing of the mitral valve which can cause pulmonary hypertension and congestion. Elevated pressure in the left atrium causes increased pressure to the pulmonary artery which can result in right ventricular hypertrophy and right-sided heart failure

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? A. Visualizing the eardrum before irrigating B. Instilling 50 mL of fluid with each irrigation C. Using firm, continuous pressure while irrigating D. Warming the irrigation fluid to at least 37°C (98°F)

B. Instilling 50 mL of fluid with each irrigation When irrigating a client's ear, the nurse should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear, which would result in nausea, vomiting, or dizziness. The nurse should stop irrigating if the client experiences pain, nausea, vomiting, or dizziness.

A nurse is assessing a client who is recovering from a thyroidectomy and has a harsh, high-pitched respiratory sound. Which of the following actions should the nurse take? A. Hyperextend the client's neck B. Prepare for a tracheostomy C. Lower the head of the bed D. Administer morphine

B. Prepare for a tracheostomy The nurse should notify the provider immediately and prepare for a tracheostomy. Laryngeal stridor is a high-pitched, harsh breathing sound that indicates respiratory distress due to swelling, tetany, or laryngeal spasms.

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses should the nurse give? A. "Keep the lesions covered with a light sterile dressing when going outdoors." B. "Rub lesions with a washcloth to dry after washing." C. "Apply moisturizer after bathing the lesions with warm water." D. "Apply antibiotic cream twice per day until scabs form on the lesions."

C. "Apply moisturizer after bathing the lesions with warm water." use topical steroid creams, not antibiotic creams

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. "If the test is positive, it means you have an active case of tuberculosis." B. "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. "You must return to the clinic to have the test read in 2 or 3 days." The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hours indicates exposure to the tubercle bacillus. If the client does not return to have the test read within 72 hours, another tuberculin skin test is necessary.

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone

C. Aspirin Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid interaction between probenecid and salicylate medications.

A nurse is assessing a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout? A. Perimenopause B. Migraine headaches C. Diuretic use D. Irritable bowel syndrome

C. Diuretic use

A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic

C. Frontal The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

C. Report of sudden, severe back pain An aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region

C. Unilateral, localized, nodular skin lesions Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces localized, nodular skin lesions. Incorrect Answers: A. Confluent ("gathered together"), honey-colored, crusted lesions are typically associated with impetigo. B. This describes furuncle or bacterial infection on a hair follicle. D. This manifestation indicates genital herpes, which is caused by the herpes simplex virus.

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9% sodium chloride with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

C. Witness the informed consent document The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are the least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive; therefore, since witnessing the informed consent is the least invasive action, it should be performed first. Unless it is an emergency, informed consent should be obtained prior to initiating a blood transfusion for a client.

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? A. "I'm not going to be able to cough for a while after the surgery." B. "After I recover from the anesthesia, I'll be able to eat regular food again." C. "After the surgery, my voice will gradually return but might be weak." D. "I understand that I will have a permanent tracheostomy after the surgery."

D. "I understand that I will have a permanent tracheostomy after the surgery." With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent.

A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A. "In case you had the immunization before, we can't give you another one." B. "You'll need a series of 3 injections." C. "This immunization is unsafe for people over the age of 65 years old." D. "Let's go ahead and give you this immunization."

D. "Let's go ahead and give you this immunization." The Centers for Disease Control and Prevention recommend this immunization for people who are 65 years of age and older. If the client did receive this immunization more than 5 years ago, the nurse should administer another because the client is over 65

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to clean lesions B. Wear a condom during sexual activity when lesions are present C. Take a sitz bath once per day D. Apply a warm compress to the lesions

D. Apply a warm compress to the lesions The nurse should instruct the client to apply a warm compress to the lesions to relieve discomfort.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? A. Have the client gently blow clots from the nose every 5 min B. Instruct the client to sit with his head hyperextended C. Apply ice compresses to the back of the client's neck D. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures? A. Exploratory laparotomy B. Double-contrast barium enema C. Magnetic resonance imaging D. Colonoscopy

D. Colonoscopy A colonoscopy requires the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. It can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of bleeding.

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position B. Apply cold compresses to painful joints C. Withhold opioids until the crisis is resolved D. Encourage increased fluid intake

D. Encourage increased fluid intake The nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can aggravate sickling and client discomfort.

A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? A. Offer graham crackers as a snack B. Avoid foods containing citrus C. Rinse the mouth with an alcohol-based mouthwash before eating D. Use gravies or sauces to soften food

D. Use gravies or sauces to soften food Makes them easier to eat

A nurse is assessing a client who has COPD and a prescription for ipratropium. The nurse should monitor the client for which of the following adverse effects of this medication? a. Dry mouth b. Diarrhea c. Urinary frequency d. Nystagmus

a. Dry mouth

A nurse is teaching a newly licensed nurse about preventing a catheter-associated urinary tract infection for a client who has an indwelling urinary catheter. Which of the following instructions should the nurse include? a. Ensure the urinary catheter tubing is not kinked. b. Rest the catheter bag on the floor when the client is sitting in a chair. c. Clean the perineal area with an antiseptic solution. d. Empty the collection bag for the client every 12 hr.

a. Ensure the urinary catheter tubing is not kinked. The nurse should instruct the newly licensed nurse to make certain the catheter tubing if free of kinks, which could cause a blockage of urinary flow and result in a UTI.

A nurse is documenting in the medical record for a client who has just completed a transfusion of 1 unit of packed RBCs. Which of the following information should the nurse include in the post-transfusion documentation a. the unit number from the client's blood product label b. the amount of the client's meal consumed during the transfusion c. the number of times the client voided during the transfusion d. the current list of the client's allergies

a. the unit number from the client's blood product label

A nurse is evaluating a client who is receiving chemotherapy and has decreased oral intake from stomatitis. Which of the following actions should the nurse take? a. Use glycerin-based mouthwashes. b. Offer oral hygiene after meals. c. Examine the client's mouth every shift. d. Offer warmed liquids to sip.

b. Offer oral hygiene after meals.

A nurse is assessing a client who has COPD. The nurse should identify that which of the following findings is a priority to update the client's plan of care? a. barrel shaped chest b. dependent edema c. clubbed fingers d. productive cough with clear sputum

b. dependent edema