ATI practice assessment A
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature
A, B, C - Increased heart rate is correct: The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. - Increased blood pressure is correct: The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. - Increased respiratory rate is correct: The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.
A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply.) A. Erythema B. Damp dressing C. Throbbing D. Warmth at insertion site E. Streak formation
A, C, D, E
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? A. "I am thinking of getting a second opinion." B. "I am hoping this will limit my discomfort." C. "This treatment should help me live a little longer." D. "This is not working and I plan to stop treatment."
B. "I am hoping this will limit my discomfort." Clients receiving palliative care are aware that the outcome is to prevent suffering and provide the best possible quality of life.
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." B. "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." C. "Exercise is good for you and good for your heart." D. "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A. A client who has diarrhea B. A client who is vomiting C. A client who is taking a thiazide diuretic D. A client who has salicylate intoxication
A. A client who has diarrhea - Diarrhea can cause metabolic acidosis due to the loss of bicarbonate. - Vomiting can cause metabolic alkalosis due to acid loss. Thiazide diuretics can cause metabolic alkalosis due to excretion of acid. Salicylate intoxication can cause respiratory alkalosis due to carbon dioxide loss from tachypnea.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
A. Airway obstruction
A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? A. WBC 2300/mm3 B. RBC 5 million/mm3 C. Hemoglobin 12 g/dL D. Platelets 155,000/mm3
A. WBC 2300/mm3 Normal WBC levels are 4,000-10,000. This WBC finding is below the expected reference range. Chemotherapy treatment can cause leukopenia; the nurse should report this finding to the provider and implement precautions to protect the client from infection.
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight B. A client who has terminal cancer and needs assistance with pain management C. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work D. A client who has dementia and needs help with activities of daily living
B. A client who has terminal cancer and needs assistance with pain management A client who has a terminal disease and who is deemed to have less than 6 months to live is eligible for hospice services. Hospice care provides the client with physical and psychological support, which includes management of symptoms, such as pain and dyspnea.
A nurse is planning a community diabetes mellitus management program. Which of the following goals should the nurse include for the program? A. Proper foot care will be demonstrated to clients during the program. B. Clients will have a decreased incidence of foot amputations. C. A facility will be reserved for the program. D. Handouts and teaching materials will be distributed at the program.
B. Clients will have a decreased incidence of foot amputations. A goal is the desired result toward which effort is directed. A reduced incidence of foot amputations is an appropriate, measurable, and realistic goal for a community diabetes management program.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? A. All visitors from entering the client's room B. Fresh flowers and potted plants in the room C. Oral fluid intake to between meals only D. Activities that could result in bleeding
B. Fresh flowers and potted plants in the room
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A. Chest x-ray B. Sputum culture for acid-fast bacillus C. Sputum smear D. Mantoux test
B. Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia B. hoarseness. C. dyspnea. D. weight loss.
B. hoarseness.
A nurse is teaching a client who has diabetes mellitus and receives 25 units of PH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? A. Discard the NPH solution if it appears cloudy. B. Shake the insulin vigorously before loading the syringe. C. Expect the NPH insulin to peak in 6 to 14 hr. D. Freeze unopened insulin vials.
C. Expect the NPH insulin to peak in 6 to 14 hr. PH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14 hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak time.
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning
C. Performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.
A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client? A. Short peripheral catheter B. Implanted infusion port C. Peripherally inserted central catheter D. Arteriovenous fistula
C. Peripherally inserted central catheter A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines can also be used to draw blood samples without the need for additional venipunctures.
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
C. Verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic B. anti-inflammatory C. antiplatelet aggregate D. antipyretic
C. antiplatelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.
A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? A. A client who has a urine specific gravity of 1.010. B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr. C. A client who has a hematocrit of 45% D. A client who has a temperature of 39° C (102° F)
D. A client who has a temperature of 39° C (102° F) This temperature is greater than the expected reference range of 36° C (96.8° F) to 37° C (98.6° F). An elevated temperature is a manifestation of dehydration.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily
D. Encouraging the client to drink 2 to 3 L of water daily Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain usually lasts longer than 20 min. B. The pain often radiates to the jaw or the back. C. The pain persists with rest and organic nitrates. D. Exertion and anxiety can trigger the pain.
D. Exertion and anxiety can trigger the pain.
A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? A. Hypothermia B. Protruding eyeballs C. Elevated blood pressure D. Furrows in the tongue
D. Furrows in the tongue In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.
A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level? A. Furosemide B. Nitroglycerin C. Metoprolol D. Spironolactone
A. Furosemide Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.
D. The client who has gastroenteritis and is febrile. This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output
A. Daily weight Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub C. The third heart sound (S3) D. A split second heart sound S2
A. The fourth heart sound (S4) S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight
B. Heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times. D. Empty the collection chamber prior to transport.
C. Keep the drainage system below the level of the client's chest at all times.
A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright
A. Breathing ranging from very deep to very shallow with periods of apnea
A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.) A. A nonhealing sore B. Bloating C. Change in bowel pattern D. Change in moles E. Nagging cough
A, C, D, E
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy
A. Discontinue the existing IV line.
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention
A. Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness. All the other options are signs of right-sided heart failure.
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A. Oral mucosa B. Conjunctivae C. Ear lobes D. Soles of the feet
A. Oral mucosa According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? - pH 7.22 - PaCO, 68 mm Hg - Base excess -2 - Pa02 78 mm Hg - Saturation 80% - Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis
A. Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (02 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a COz level that is higher than the normal reference range (35 - 45 mm Hg).
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? A. Epinephrine B. Magnesium C. Atropine D. Sodium bicarbonate
C. Atropine The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable. - The team administers epinephrine during CPR to clients who have systole or pulseless electrical activity. - The team administers magnesium during CPR for clients who have torsade de pointes, which is a specific type of ventricular tachycardia. - The team administers sodium bicarbonate to correct metabolic acidosis that does not improve with CPR.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A. Talking to the client at the bedside B. Administering an intermittent IV bolus medication C. Completing a dressing change D. Administering an IM injection
C. Completing a dressing change Standard precautions require personal protective equipment when there is a risk of contact with body fluids. A dressing change does present a risk for coming into contact with body fluids.
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 moves 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 Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out. - Atelectasis is a collapse of the alveoli. With atelectasis, the exchange of oxygen and carbon dioxide is diminished. Crackles, fever and productive cough are manifestations of atelectasis. - Hemothorax is blood in the pleural space and involves decreased movement of the involved chest wall. Manifestations of a large hemothorax include diminished breath sounds and dull percussion sounds. - Pneumothorax is air in the pleural space and involves decreased movement of the involved chest wall. Manifestations of pneumothorax include diminished breath sounds and hyperresonance upon percussion.
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.
B. It facilitates the client's deep breathing. When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief. Following thoracic type surgeries, the client's has increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experienced with deep breathing and coughing which prevents the development of postoperative pneumonia. The nurse should also encourage the client to splint his incision to help minimize pain.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? A. 0720 B. 0730 C. 0745 D. 0815
C. 0745 Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30 minutes.
A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C. Confirming the gag reflex When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway.
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 pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 36.1° C (97.0° F) B. Insomnia C. Oliguria D. Weight loss
C. Oliguria
A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care? A. Use aseptic technique. B. Clean the inner cannula with mild soap and water. C. Secure new tracheostomy ties before removing old ones. D. Apply suction when inserting the catheter.
C. Secure new tracheostomy ties before removing old ones. Tube dislodgement and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying new ties, the nurse can secure the tube and prevent dislodgement.
A charge nurse is planning to admit several clients to the medical unit. Which of the following clients should the nurse assign to a private room? A. A client who has a fever of unknown origin B. A client who had a total hip arthroplasty C. A client who is HIV positive D. A client who is neutropenic
D. A client who is neutropenic Clients who have neutropenia (a low count of neutrophils, a type of WBC that helps fight infection) due to immune system compromise, such as clients who have leukemia or major burns or are receiving chemotherapy or allogenic hematopoietic stem cell transplants, require a protective environment to prevent the spread of pathogens to the clients requiring the protective environment. This means a private room with positive airflow.
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.
D. Administer oxygen via nasal cannula. The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make? A. Provide the client with articles from the Internet that explain colon cancer stages. B. Assure the client that the provider will explain what has been planned. C. Explain the various options available for treatment based on the cancer stage. D. Encourage the client to write down questions to ask the provider.
D. Encourage the client to write down questions to ask the provider. The nurse does not know the answers to the client's questions, so helping the client to prepare questions for the provider addresses the client's needs.
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min. B. Decrease in the urinary output from 50 ml to 30 mL per hour. C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). D. Increase in the heart rate from 88 to 110/min.
D. Increase in the heart rate from 88 to 110/min. Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate increases steadily. In the first stage of shock (compensatory), the heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning.
D. Perform pre-oxygenation prior to suctioning Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.