ATI MS B

A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching?

The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways.

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.

The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching?

The nurse should instruct the client that constipation is an adverse effect of verapamil. The client should increase fiber intake to promote regular bowel function. The nurse should instruct the client to monitor blood pressure weekly and report manifestations of hypotension to the provider.

food allergy r/t propofol

Peanuts Eggs

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? Flush the line before administering antibiotics. Position the client in Trendelenburg to obtain measurements. Have the client bear down when readings are obtained. Place a pressure bag around the flush solution.

Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

osteoporosis meds:

calcitonin estrogen riloxafine alendrogen

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?

Avocados MY ANSWER 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 caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

Bubbling in the water seal chamber ceases when the lung re-expands.

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. MY ANSWER The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis?

Prednisone MY ANSWER The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

Circulatory overload occurs when the infusion rate is

faster than the client can tolerate. Manifestations include - hypertension, restlessness, and a bounding pulse.

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 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. Vitamin C increases the absorption of iron. If your patient is taking an iron supplement, be sure they eat foods rich in Vitamin C! Examples: citrus fruit or juices, tomatoes, green leafy vegetables, peppers.

Allergic transfusion reactions can occur up to

24 hr following a transfusion and include manifestations such as bronchospasm, urticaria, and anaphylaxis.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

AD is an exaggerated response to stimuli in clients who have high-level spinal injuries. Untreated, AD can result in stroke, organ damage, or death. Manifestations of AD include diaphoresis above the site of the spinal cord injury, but an elevated temperature is not a manifestation of AD. Heart rate 52/min A client who is experiencing AD will exhibit: -extreme hypertension , severe headache, blurred vision, severe headache, and flushing. >sit the pt up> unkink foley tubing,

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy. Family members should follow airborne precautions at home. A follow-up tuberculosis skin test is necessary in 2 months.

After three negative sputum cultures, the client is no longer considered infectious.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Applying oxygen via face mask Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? Obtain the client's vital signs. Describe the blood transfusion procedure to the client. Check for the type and number of units of blood to administer. Initiate a peripheral IV line.

Check for the type and number of units of blood to administer. MY ANSWER According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client's medication administration record.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

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 providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? Drink 240 mL (8 oz) of water after administration. Expect results in 4 to 6 hr. Take this medication before meals to increase appetite. Reduce dietary fiber intake to improve medication absorption.

Drink 240 mL (8 oz) of water after administration.

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? After 1 week of medication, TB is no longer communicable. Dispose of contaminated tissues in a paper bag. Airborne precautions are necessary in the home. Family members in the household should undergo TB testing.

Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? "Ginkgo biloba relieves nausea for people who have vertigo." "Taking ginkgo biloba will help relieve your joint pain." "Ginkgo biloba can cause an increased risk for bleeding." "Taking ginkgo biloba decreases the risk of migraine headache."

Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL A glucose reading less than 300 mg/dL indicates improvement in the client's status.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

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 providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? "I will eat a salad at least once each day to increase my intake of vitamin K." "I can work in my flower garden as long as I wear gardening gloves to cover my skin." "I will no longer floss my teeth after brushing my teeth." "I can sip on a glass of juice for at least 2 hours before I should discard it."

I will no longer floss my teeth after brushing my teeth." The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection.

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 1INR, along with PT, is obtained to measure the clotting abilities of the blood in a client who is taking warfarin. This INR value is below the target reference range for a client who has atrial fibrillation. INR 2.5MY ANSWERClients 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. aPTT 45 secondsClients who are receiving heparin should have aPTT levels monitored to ensure appropriate anticoagulation is achieved. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds. aPTT 90 secondsaPTT is obtained to measure the clotting abilities of the blood. In a client who is receiving heparin therapy, the therapeutic range for an aPTT value is 1.5 to 2 times the expected reference range of 30 to 40 seconds.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

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 caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

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?

Pain that increases with passive movement MY ANSWER 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 has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Obtain a sputum specimen to determine if there is colonization. Bathe the client using chlorhexidine solution. Place the client in droplet isolation. Restrict visits from the client's friends and family.

The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? The client starts to cough. The client's heart rate increases. The client is diaphoretic. The client's blood pressure decreases.

The nurse should expect the client to cough during suctioning of a tracheostomy due to bronchial stimulation. Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia. Diaphoresis is not associated with suction-induced hypoxia. However, long-term hypoxia can lead to diaphoresis. A client's blood pressure can increase initially with hypoxia. If this occurs, the nurse should stop suctioning and manually oxygenate the client. Long-term hypoxia can lead to a decrease in blood pressure and shock.

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?

The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer ranitidine when the client is no longer bleeding.

A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Walk for 30 min four times per week. MY ANSWER Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? Moderate serosanguinous drainage on the dressing Calcium 9.5 mg/dL Temperature 38.9° C (102° F) Decreased bowel sounds

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.

Hemolytic transfusion reactions result from the infusion of

incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.