Ati AMS ver1

Potassium 5.2 mEq/L

1. A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

- Lymphedema

99. A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?

- Apply a calcium alginate dressing to the client‟s scapulae

A nurse is assessing an older adult client who has right hemiplegia. The nurse notes 3 cm (1.2in) pink-red areas on both of the client‟s scapulae. Which of the following actions by the nurse is appropriate?

a. I will spread my protein allowances over the entire day

a nurse providing teaching for a client who has chronic kidney disease. which of the following client statements indicates an understanding of the teaching?

A . begin CPR

32. A nurse is caring for a client in the emergency department following a myocardial infarction. Which of the following actions should the nurse anticipate if the client develops asystole?

- blurred vision

10. A nurse in a long-term care facility caring for a bedridden. Which of the following findings should alert the nurse to a complication of the client‟s immobility?

- Feet elevated (modified Trendelenburg)

100. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?

c. "The elastic bandage will prevent excessive edema."***

11. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? a. "The elastic bandage will keep you from seeing the surgical site." b. "The elastic bandage will prevent a postoperative wound infection." c. "The elastic bandage will prevent excessive edema."*** d. "The elastic bandage will keep the sutures from loosening."

d. Administer the plasma immediately after thawing

12. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Hold the transfusion if the client is actively bleeding b. Transfuse the plasma over 4 hours c. Administer the transfusion through a 25-gauge saline lock d. Administer the plasma immediately after thawing

d. Administer 0.9% sodium chloride

13. A nurse caring for a client in diabetic ketoacidosis (DKA) , Which of the following is the priority intervention by the nurse a. Initiate a continuous IV insulin infusion b. Begin bicarbonate continuous IV infusion c. Check potassium levels d. Administer 0.9% sodium chloride

B. 5

14. 1. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glascow Coma Scale scores should the nurse assign the client?

c. "I will expect my stools to be loose."**

15. 1. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

"Use a 10-milliliter syringe when flushing the catheter."

16. A home health nurse is teaching a client how to care for a peripherally inserted central catheter in his right arm. Which of the following statements should the nurse include in the teaching?

b. Check the color of the client‟s skin.

17. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first? a. Administer an opioid analgesic b. Check the color of the client‟s skin. d. Prepare the client for peritoneal lavage.

a. Crackles in bilateral lower lobes

18. A nurse is assessing a client who has parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to intervene?

a. Shortness of breath

19. A nurse working in the emergency department is assessing a client admitting with atrial fibrillation. Which of the following findings should the nurse report to the provider immediately?

"Stand upright" "Fill your lungs with a deep breath." "Seal your lips around the mouthpiece." "Exhibit forcefully and quickly." "Record the highest of three consecutive readings."

2. A nurse is teaching a client who has asthma the use of a peak flow meter. After setting the meter to the zero baseline. What is the sequence of steps the nurse should instruct the client to take? (Move the steps into the box on the right, placing them in the selected order of performance use all the steps.) "Stand upright" "Fill your lungs with a deep breath." "Seal your lips around the mouthpiece." "Exhibit forcefully and quickly." "Record the highest of three consecutive readings."

a. 0.9% sodium chloride IV solution

20. A nurse is reviewing a medical record of a client who has heat exhaustion with nausea and vomiting. Which of the following prescriptions should the nurse expect to administer?

a. "I should expect less than 25 mL of secretions per day in the drainage devices."

21. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

MENTAL CONFUSION

22. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding?

d. Hypocalcemia

23. A nurse is assessing a client who reports numbness and tingling and exhibits a positive Trousseau‟s sign. Which of the following electrolyte imbalances should the nurse suspect?

d. Palpate the site for a thrill.

24. A nurse is planning care of a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

a. Flush the catheter manually with 0.9% sodium chloride. **

25. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client acute pancreatitis and has been receiving total reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take? a. Flush the catheter manually with 0.9% sodium chloride. ** b. Decrease traction on the catheter. c. Administer ibuprofen 400 mg for pain relief. d. Remove the indwelling urinary catheter.

b. Wash your perineal area two times each day with antimicrobial soap

26. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

b. "I rest my recliner with my feet elevated for about an hour every afternoon."***

27. 1. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching? a. "I use my heating pad on a low-setting to keep my feet warm." b. "I rest my recliner with my feet elevated for about an hour every afternoon."*** c. "I apply a lubricating lotion to the cracked areas on the soles of my feet every morning." d. "I soak my feet in hot water before trimming my toenails."

b. Proteinuria

28. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?

A

29. 1. A nurse in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infarction? (ST elevation)

- Feet elevated

3. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?

a. Tap the skin around the insertion site

30. A nurse is performing a venipuncture on an older adult client whose veins are difficult to locate. Which of the following actions should the nurse take? a. Tap the skin around the insertion site b. Apply a cool compress to the extremity c. Elevate the client‟s extremity using pillow d. Raise the angle of the catheter to 30 degrees above the insertion site.

d. "Exhale fully before bringing the inhaler to your lips." ***

31. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. "Depress the canister after you inhale."** b. "Use peroxide to clean the mouthpiece of your inhaler." c. "Do not shake your inhaler before use." d. "Exhale fully before bringing the inhaler to your lips." ***

b. Program the client‟s PCA dosage parameters with another nurse***

33. A nurse is caring for a client who has acute pancreatitis and a new prescription for a patient- controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

- Increased serosanguineous drainage from the wound***

34. 1. A nurse is caring for a client who is 5 days postoperative following a total abdominal hysterectomy. Which of the following findings indicates dehiscence?

b. Check for bubbling in the water seal chamber.

35. 1. A nurse is planning care for a client who has a chest drainage system set to low suction following a thoracotomy. Which of the following nursing actions is appropriate to include in the plan of care?

d. Prepare the client for temporary pacing.

36. A nurse is caring for a client who develops a third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take?

d. Administer the transfusion over a 4-hour period***

37. A nurse is caring for an older adult client who is prescribed packed RBCs. Which of the following actions is appropriate for the nurse to take?

d. Assess urine output hourly.

38. A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

b. You will no longer to contagious after three consecutive negative sputum

39. A nurse is providing teaching to a client who has tuberculosis. Which of the following is appropriate for the nurse to include in the teaching? a. You will need to continue to have yearly tb skin tests b. You will no longer to contagious after three consecutive negative sputum specimens c. You should expect to take the prescribed medication therapy for 2 months D. You should avoid consuming fresh fruit and vegetables during therapy

b. You will no longer to contagious after three consecutive negative sputum specimens

39. A nurse is providing teaching to a client who has tuberculosis. Which of the following is appropriate for the nurse to include in the teaching? a. You will need to continue to have yearly tb skin tests b. You will no longer to contagious after three consecutive negative sputum specimens c. You should expect to take the prescribed medication therapy for 2 months D. You should avoid consuming fresh fruit and vegetables during therapy

a. Assess the client‟s stools for occult blood

4. A nurse is planning care for a client who has a pulmonary embolism and a prescription for enoxaparin via subcutaneous injection. Which of the following interventions should the nurse include?

b. "I will check my urine for ketones if my blood glucose is greater than 240 mg/dL.

40. 1. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching?

a. Generalized rash **

41. A nurse is caring for a female client who has toxic shock syndrome. Which of the following should the nurse expect? a. Generalized rash ** b. Hypertension (hypotension) c. Elevated platelet count d. Decreased total bilirubin

b. Blood pressure

42. A nurse is caring for a client who has traumatic brain injury. The client, who has been quiet and cooperative. Becomes agitated and restless. Which of the following assessments should the nurse perform first?

d. The client‟s capillary refill in the left toe is 6 seconds.

43. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?

a. Amiodarone

44. A nurse is caring for a client who has atrial fibrillation. Which of the following medications should the nurse expect to administer?

d. Trim toenails straight across.

45. A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include?

c. WBC count of 16,000/mm3

46. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider?

- Determine priority activities to accomplish

47. A nurse is caring for a client who has rheumatoid arthritis and reports increased fatigue. The nurse should instruct the client to take which of the following actions to conserve energy?

d. Metabolic acidosis

48. 51. A nurse in the intensive care unit is caring for a patient who has the following ABG results: pH, 7.30; HCO3 19 mEq/L; PaO2 and PaCO2 within the expected reference ranges. The nurse should expect to provide treatment for which of the following conditions?

D. absence of a bruit

49. A nurse is assessing a client who has an arteriovenous (AV) fistula in the left forearm. Which of the following findings should the nurse identify as an indication of a complication at the vascular access site?

limit family member visits to 30 min per day

5. a nurse is caring for a client who has sealed radiation implant. which of the following actions should the nurse take?

D. platelets 70,000/mm3

50. 39. A nurse is caring for a patient who has thrombocytopenia. Which of the following laboratory results should the nurse expect?

- The elastic bandage will prevent excessive edema

50. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the ?

- Metabolic acidosis

51. A nurse in the intensive care unit is caring for a client who has the following ABG results: pH 7.30; HCO3 19 mEq/L;PaO 2 and PaCO2 within the expected reference ranges. The nurse should expect to provide treatment for which of the following conditions?

- Upright on the edge of the bed leaning over the bedside table

52. A nurse preparing a client who is to undergo a thoracentesis. The nurse should place the client in which of the following positions?

- I will notify my provider if i experience muscle weakness

53. A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?

- Verify the solution with another RN prior to infusion - Obtain the client‟s weight daily - Monitor serum blood glucose during administration

54. A nurse caring for a client who receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate (Select all that apply). - Verify the solution with another RN prior to infusion - Obtain the client‟s weight daily - Monitor serum blood glucose during administration

- Maintain the client‟s affected extremity in extension

55. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take?

- PaCO2 50 mmHg

56. A nurse reviewing the laboratory results of a client who has COPD and severe dyspnea. Which of the following ABG values should the nurse expect?

- I will check my urine for ketones if my blood glucose is greater than 240 mg/dL

57. A nurse instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching?

- A client with acute kidney injury and has a potassium level of 6.5 mEq/L

58. A nurse on an acute care unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

- "I should lie down before taking a dose of isosorbide dinitrate."

59. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

- Assess urine output hourly

60. A nurse planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

- Controlling hypertension

61. A nurse is providing teaching to a client who has diabetes mellitus. Which of the following instructions should the nurse provide to the client to help prevent the development of nephropathy?

- Limit family visits to 30 minutes a day

62. A nurse caring for a client who has a sealed radiation Implant. Which of the following actions should the nurse take?

- a. I will spread my protein allowances over the entire day

63. A nurse providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client Indicates an understanding of the teaching?

- Syncope

64. A nurse working in the emergency department is assessing a client admitted with atrial fibrillation. Which of the following findings should the nurse report to the provider immediately?

- Hemoglobin 10 mg/dL

65. A reviewing medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

- Determine priority activities to accomplish

66. A nurse is caring for a client who has rheumatoid arthritis and reports increasing fatigue. The nurse should instruct the client to take which of the following actions to conserve energy?

- Your cough may require that you stop or change your medication

67. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough . Which of the following responses by the nurse is appropriate ?

- Wash your peritoneal area two times each day with antimicrobial soap

68. A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy . Which of the following information should the nurse include in the teaching ?

- Administer the plasma immediately after thawing

69. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Provide analgesic medication prior to physical activities.

7. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a prescription for opioid analgesia. Which of the following actions should the nurse implement to help facilitate the client's recovery? Provide analgesic medication prior to physical activities.

- echocardiogram

71. A nurse in the emergency department is reviewing the medical record of a client who is experiencing chest pain. Which of the following findings should the nurse recognize as an indication the client has recently experienced a myocardial infarction? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

- Have the client to lie down for 30 minutes after meal

72. A nurse is caring for a client who has dumping syndrome following a gastrectomy. Which of the following actions should the nurse take?

- Respiratory status

73. A nurse in the PACU is caring for a client . Which of the following assessments is the nurse's priority ?

- 200 mL/hr

74. A nurse is preparing to administer piperacillin 3 .375 g by intermittent IV bolus every 6 hr. Available is piperacillin 3.375 g in dextrose 5°/o in water (D5W) 100 ml to infuse over 30 min. The nurse should set the IV 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.)

Blood pressure

75. A nurse is caring for a client who has a traumatic brain Injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first?

- proteinuria

76. A nurse is reviewing the medical record of a client who has nephrotic syndrome . Which of the following findings should the nurse expect ?

- Use a 10-milliliter syringe when flushing the catheter

77. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching

- WBC count of 16,000/ mm 3

78. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider?

- The machine only senses and records electrical currents coming from your heart

79. A nurse is preparing a client for an ECG. The client is anxious and says that he is afraid the equipment will give him an electric shock. Which of the following is an appropriate response by the nurse?

Hemoglobin 10 mg/dL

8. A the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following should the nurse report to the provider ?

- I will keep an exercise diary

80. A nurse is teaching a client who has heart failure about self-management techniques. Which of the following statements by the client indicates an understanding of the teaching?

- hypoalbuminemia

81. A nurse is caring for a client who has deep partial -thickness burns over 15% of her body. Which of the following laboratory findings should the nurse expect during the first 24 hr ?

- Administer 0.9% sodium chloride

82. A nurse is caring for a client in diabetic ketoacidosis (DKA ). Which of the following is the priority intervention by the nurse?

- Potassium 5.2 mEq/L

83. A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

- Tap the skin around the insertion site

84. A nurse is performing a venipuncture on an older adult client whose veins are difficult to locate. Which of the following actions should the nurse take?

- Blanching of the hands

85. A nurse is assessing the extremities of a client who has Raynaud‟s disease. Which of the following findings should the nurse expect?

- Remove all of the client's clothing

86. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?

- Hold breaths 3 to 5 seconds before exhaling

87. A nurse is teaching a client about the use of the incentive spirometer. Which of the following instructions should the nurse include in the teaching?

- Trim toenails straight across

88. A nurse providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include?

- 0.9% sodium chloride IV solution

89. A nurse is reviewing the medical record of a client who has heat exhaustion with nausea and vomiting . Which of the following prescriptions should the nurse expect to administer ? ( Click on the "Exhibit " button for additional Information about the client. There are three tabs that contain separate categories of data .)

A client who had an acute kidney injury and has a potassium level of 6.5 mEq/L

9. A nurse on an acute care unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse assess first?

- Verify the placement with an x-ray prior to the initial dose

90. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take?

- A client who has pancreatitis reports pain in the left shoulder

91. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain?

- WBC count 15,000/mm

92. A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect?

- Determine whether the client has an allergy to local anesthetics

93. A nurse is preparing to assist the provider with thoracentesis for a client who has left pleural effusion. Which of the following interventions is the priority for the nurse?

5

94. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow coma scale scores should the nurse assign the client?

- Hypotension

95. A nurse is caring for a client who is receiving epidural analgesia. Which of the following findings is the nurse‟s priority?

- "This is an expected adverse effect of this medication."

96. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red- orange in color. Which of the following responses should the nurse make?

- Desmopressin (controls excessive amount of water/ urine)

97. A nurse is caring for a client who has contusion of the brainstem and reports thirst. The client‟s urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications?

- Suction the tube if the low-pressure alarm sounds

98. A nurse is planning care for a client who is receiving mechanical ventilation through an endotracheal (ET ) tube . Which of the following actions should the nurse take ?