ATI NUR 2241 LP4

A nurse is caring for a client who asks about the functions of the thymus, spleen, and lymph nodes. Which of the following responses should the nurse make? a. "These organs support immunity." b. "These organs are used in digestion." c. "These organs regulate electrolyte balance." d. "These organs assist vitamin absorption."

a. "These organs support immunity."

A nurse is reviewing guideline for prophylactic antibiotics. The nurse should identify that prophylactic therapy is not recommended for which of the following client? a. A client who has a fever of unknown origin b. A client who has a prosthetic heart valve is having dental surgery c. A client following a total hip arthroplasty d. A client who had an emergency cesarean section

a. A client who has a fever of unknown origin

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for ___________. a. Side effects of immunosuppressants b. Constipation c. Fatigue d. Bleeding

d. Bleeding

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? a. Administer high-flow oxygen at 5 L/min by facemask to the client b. Place the client in high-Fowler's position with legs dependent c. Give the client sublingual nitroglycerin d. Reassure the client

a. Administer high-flow oxygen at 5 L/min by facemask to the client

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following orders? a. Carvedilol b. Fluticasone c. Captopril d. Isosorbide dinitrate

a. Carvedilol

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? a. Mask b. Gloves c. Gown d. Goggles

a. Mask

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 100/min, respiratory rate 40/min, and blood pressure 140/80 mmHg, HCO₃ mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Assess for indications of pulmonary embolism

b. Administer oxygen via face mask

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? a. Airway protection b. Decreasing intracranial pressure c. Stabilizing cardiac arrhythmias d. Preventing musculoskeletal disability

a. Airway protection

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? a. Continue to monitor the client b. Immediately notify the provider c. Reposition the client toward the left side d. Clamp the chest tube near the water seal

a. Continue to monitor the client

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

a. Continuous bubbling in the water-seal chamber

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion b. Check pupillary response to light c. Assess the capillary refill d. Check client's response to questions about place and time

a. Evaluate chest expansion

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? a. Fluctuation of the fluid level within the water seal chamber b. Absence of fluid in the drainage tubing c. Continuous bubbling within the water seal chamber d. Equal amounts of fluid drainage in each collection chamber

a. Fluctuation of the fluid level within the water seal chamber

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply) a. Severe dyspnea b. Nausea c. Decreased level of consciousness d. Headache e. Hypotension

a. Severe dyspnea c. Decreased level of consciousness d. Headache e. Hypotension

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Give morphine IV b. Administer oxygen therapy c. Start an IV infusion of lactated Ringer's d. Initiate cardiac monitoring

b. Administer oxygen therapy

A nurse is caring for a client who is 12hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? a. Constant bubbling in the suction-control chamber b. Continuous bubbling in the water-seal chamber c. Bloody drainage in the collection chamber d. Fluid-level fluctuations in the water-seal chamber

b. Continuous bubbling in the water-seal chamber

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? a. Finger b. Earlobe c. Toe d. Skin fold

b. Earlobe

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

b. Flail chest

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? a. Mask b. Gloves c. Gown d. Goggles

b. Gloves

A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? a. Febrile b. Hemolytic c. Allergic d. Bacterial

b. Hemolytic

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take? a. Place the client in a negative airflow room b. Keep blood pressure equipment in the client's room c. Monitor the client's vital signs once every 8hr d. Provide the client with 1000mL of water to drink every 12hr

b. Keep blood pressure equipment in the client's room

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? a. Clamp the tube with the client is ambulating b. Keep the collection device below the level of the client's chest c. Coil the tubes carefully to prevent kinking d. Lay the client flat to avoid leaks in the tubing

b. Keep the collection device below the level of the client's chest

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm³. Which of the following interventions should the nurse include in the plan of care? a. Check the IV site for bleeding every 8hr b. Limit IM injections c. Obtain a rectal temperature every 8hr d. Check the client for proteinuria

b. Limit IM injections

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? a. Oxygen saturation of 95% b. No fluctuations in the water seal chamber c. No reports of pleuritic chest pain d. Occasional bubbling in the water-seal chamber

b. No fluctuations in the water seal chamber

A nurse is caring for an older adult client who has a WBC count of 2000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take? a. Humidify the client's room b. Serve cooked fruit with meals c. Clean dentures in a denture cup d. Replace the water in flower vases with fresh water daily.

b. Serve cooked fruit with meals

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Report the incident to the charge nurse b. Wash the area of the puncture thoroughly with soap and water c. Complete an incident report d. Go to employee health services

b. Wash the area of the puncture thoroughly with soap and water

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? a. 1.5oz of raisins b. 8oz black tea c. 1 cup canned black beans d. 8oz whole milk

c. 1 cup canned black beans

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? a. Pinnae of the ears b. Dorsal surface of the hand c. Conjunctivae d. Dorsal surface of the foot

c. Conjunctivae

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor? a. Elevated WBC b. Fever c. Ecchymosis d. Fatigue

c. Ecchymosis

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

c. Heparin

A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1000/mm³. Which of the following interventions should the nurse include in the plan? a. Take the client's rectal temperature each day b. Increase raw procedure in the client's diet c. Limit visitors to healthy adults d. Instruct the client to floss his teeth daily

c. Limit visitors to healthy adults

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? a. Blockage of the ET tube by the client's tongue b. Passage of the ET tube into the esophagus c. Movement of the ET tube into the right main bronchus d. Infection of the vocal cords

c. Movement of the ET tube into the right main bronchus

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? a. Restlessness b. Retractions c. Dependent edema d. Clubbing of the fingers

d. Clubbing of the fingers

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? a. Intracranial pressure b. Spinal cord perfusion c. Renal function d. Hemodynamic status

d. Hemodynamic status

A nurse id planning care for a client who has acute respiratory distress syndrome (ADRS). Which of the following interventions should the nurse include in the plan of care? a. Administer low-flow oxygen continuously via nasal cannula b. Encourage oral intake of at least 3000 mL of fluids per day c. Offer high-protein and high-carbohydrate foods frequently d. Place in a prone position

d. Place in a prone position

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a. Administer oxygen at 2 L/min b. Administer prescribed analgesic medication c. Encourage coughing and deep breathing d. Raise head of bed

d. Raise head of bed