ATI Q's for Exam 2

A nurse is preparing a client who is to receive hyaluronic acid (Synvisc) injection for osteoarthritis. Which of the following statements by the nurse is appropriate?

"Hyaluronic acid is made from the skin of chickens."

A nurse is completing discharge teaching for a client who has an infection due to H. pylori (H. pylori). Which of the following statements by the client indicates understanding of the teaching?

"I will take a combination of medications for treatment."

A nurse is reinforcing teaching for a client who has a prescription for sulfasalazine (Azulfidine). Which of the following should the nurse include in the teaching?

"Notify the provider if you experience a sore throat."

A nurse is caring for a client who has heart failure and asks how to limit fluid intake to 2,000 mL/day. Which of the following is an appropriate response by the nurse?

"Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink."

A nurse is completing teaching to a client who has a new prescription for famotidine (Pepcid). Which of the following statements by the client indicates understanding of the teaching?

"i will take at meal time"

A nurse is performing health screenings of clients at a health fair. Which of the following clients are at risk for osteoporosis? (Select all that apply)

- A 40yr old client who has been taking prednisone for 4 months - A 45yr old client who takes phenytoin for seizures - A 65yr old client who has a sedentary lifestyle - A 70yr old client who has smoked for 50 years

A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension?

- Eating popcorn at the movie theater - Consuming 36 oz of beer daily

A nurse is admitting an older adult client who has suspected osteoporosis. Which of the following is a risk factor? (Select all that apply)

- loss in height of 2 in. (5 cm) - kyphotic curve at upper thoracic spine - BMI of 18 - history of lactose intolerance

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8°C (100 F) respirations 30 per minute, blood pressure 130/76, heart rate 100 bpm and SaO2 91% on room air. Prioritize the following nursing actions

1.Administer oxygen therapy 2.Perform a sputum culture 3. administer antibiotics. 4. Administer an antipyretic medication to promote client comfort

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply)

A. "I will clean the pins twice a day" B. "I will use a separate cotton swab for each pin" C. "I will report loosening of the pins to my doctor"

A nurse is providing information about probiotic supplements to a male client. Which of the following information should the nurse include? (Select all that apply.)

A. "Probiotics are micro-organisms that are normally found in the GI tract." B. "Probiotics are used to treat clostridum difficile." D. "You can experience bloating while taking probiotic supplements."

A nurse is monitoring a group of clients for increased risk of developing pneumonia. Which of the following client should the nurse expect to be at risk (select all that apply)

A. A client who has dysphasia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines?

A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit total suctioning time to 5 minutes.

A nurse is caring for a client who has a tracheostomy. Which of the following action should the nurse take when providing tracheostomy care?

A. Apply the oxygen source loosely if the Spo2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward.

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should be consumed in limited quantities? (Select all that apply.)

A. Cheddar cheese, 2 oz B. Hot dog C. Canned tuna, 3 oz E. Baked ham, 3 oz

A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications? Select all that apply.

A. Dyspnea- can indicate a pneumothorax or reaccumulation of fluid C. Fever- can indicate an infection D. Hypotension- can indicate intrathoracic bleeding

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.)

A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. E. Include omega-3 fatty acids in the diet.

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis? (Select all that apply.)

A. Emesis greater than 500 mL with a fecal odor B. Report of spasmodic abdominal pain C. Pain relieved with vomiting

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? (Select all that apply.)

A. Evaluate intake and output. B. Monitor laboratory reports of electrolytes. E. Observe stool characteristics.

A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following should be included in the teaching? (Select all that apply.)

A. Increased flatulence can occur following the procedure. B. NPO status should be maintained preprocedure.

A nurse is assessing a client who had an external fixation device applied 2h ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome? (Select all that apply)

A. Intense pain when the client's left foot is passively moved C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? Select all that apply.

A. Nail polish B. Inadequate peripheral circulation E. Edema

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? Select all that apply.

A. Oxygen equipment C. Pulse oximeter D. Sterile dressing

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurses that the client is developing hypoxemia?

A. Restlessness B. Tachypnea D. Confusion E. Pallor

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following are expected findings? (Select all that apply.)

A. Rigid abdomen B. Tachycardia e. Rebound tenderness

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following are expected findings? (Select all that apply.)

A. Tachypnea B. Persistent cough E. Orthopnea

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole (Nexium). Which of the following should be included in the teaching? (Select all that apply.)

A. Take the medication 1 hr before a meal. B. Limit NSAIDs when taking this medication.

A nurse is providing teaching to a client who is starting simvastatin. Which of the following information should the nurse include in the teaching?

A. Take this medication in the evening.

A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism (select all)?

A. a client who has a BMI of 30 C. a client who has a fractured femur E. a client who has chronic atrial fibrillation

A nurse is preparing to administer a morning dose of aspart insulin (NovoLog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse?

Administer the insulin when breakfast arrives.

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first?

Assist the client into high-Fowler's position.

A nurse is completing discharge teaching to a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following statements by the client indicates understanding of the teaching?

B. "I will eat more baked potatoes."

A nurse is monitoring a client who takes aspirin 81 mg PO daily. The nurse should identify which of the following manifestations as adverse effects of daily aspirin therapy? (Select all that apply.)

B. Coffee-ground emesis C. Tinnitus E. Nausea

A nurse is completing an admission assessment of a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? (Select all that apply.)

B. Urine specific gravity 1.040 C. Hematocrit 60% D. Serum potassium 3.0mEq/L

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care?

Buck's traction

A nurse is planning care for a client who has a small bowel instruction and a nasogastric (NG) tube in place. Which of the following nursing interventions should be included in the plan of care? (Select all that apply.)

C. Assess bowel sounds. D. Provide oral hygiene every 2 hr. E. Clamp the NG tube during ambulation.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?

C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "No Smoking" signs in a prominent location.

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following are expected findings? (Select all that apply.)

C. Client reports a sensation of bloating. D. Client states that pain occurs ½ to 1 hr after a meal.

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.)

C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

A nurse is reviewing the bowel prep using polyethylene glycol (GOLYTELY) with a client scheduled for a colonoscopy. Which of the following should be included in the teaching?

Check with the provider about taking current medications when consuming bowel prep.

A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (select all that apply)

Diuretic use Obesity Cardiovascular disease

A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action?

Draw up and administer regular and glargine insulin in separate syringes.

A nurse is reviewing the health record of a client who is being admitted with a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following tests?

GI Xray with contrast

A nurse is reviewing prescribed medications for an older adult client. Which of the following medications could result in sodium and potassium loss?

HCTZ

A nurse is reviewing the clinical manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply.)

Heat intolerance, Palpations, Weight loss: Hyperthyroidism increases the client's metabolism. Therefore, these are an expected finding.

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following clinical manifestations should the nurse expect to find?

Heberden's nodes, enlarged joint size, limp when walking

A nurse is caring for a client who has a new diagnosis of hypertension and a new prescription for spironolactone (Aldactone) 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching?

I should report any changes in heart rate to the doctor

Nurse is teaching a group of clients about influenza which of the following client statements indicate an understanding of the teaching

I should wash my hands after blowing my nose to prevent spreading the virus

A nurse in the clinic is assessing a client who has sinusitis which of the following techniques should the nurse use to identify manifestations of this disorder

Palpation of the orbital areas

A nurse is caring for a client who requests information on the use of feverfew. Which of the following responses should the nurse make?

It can decrease the frequency of migraine headaches

A nurse is providing dietary teaching about calcium-rich foods to a client to has osteoporosis. Which of the following foods should the nurse include in the instructions?

Kale

A nurse is caring for a client who has increased liver enzymes and is taking herbal supplements. Which of the following herbal supplements should the nurse report to the provider?

Kava

A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first?

Provide 4 oz grape juice.

A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching?

Remove throw rugs in walkways Use prescribed assistive devices Remove clutter from the environment Maintain lighting of doorway areas

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider?

Takes metoprolol (Lopressor) in the evening

A nurse is providing care to a client who is 1 day postoperative paracentesis. The nurse observes clear, pale‑yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention?

dry sterile dressing

a nurse is providing dietary instructions to a client who is recovering from acute gastroenteritis and has been advised to limit his intake to low fat foods. the nurse should suggest that the client eat which of the following foods? (select all)

a. saltine crackers b. oatmeal d. canned peaches e. pretzels

A nurse is completing a nursing history for a client who takes simvastatin. The nurse should identify which of the following disorders as a contraindication to adding ezetimibe to the client's medications?

active hep C

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vita signs are: HR 117/min, RR 38/min, T 101.2F, BP 100/54 mmHg. Which of the following actions is the priority action at this time?

admin 02

A nurse is caring for a pt with a new dx of macular degeneration. what statement should the nurse include in the teaching?

administer eye drops twice daily

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat emboli?

altered mental status

A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should anticipate prescriptions by the provider for which of the following medications? (Select all that apply.)

antacids H2 receptor antagonists PPIs

A nurse is completing discharge teaching for a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include in the teaching?

antibiotics should continue for 3 months (red on PP aka know this)

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information?

apply heat to joints to alleviate pain, ice inflamed joints following activity, install an elevated toilet seat, complete high-energy activities in the morning

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse?

assess airway

a nurse is reviewing the health record of a client who asks about using propranolol to treat hypertension. the nurse should recognize which of the following conditions is a contradiction for taking propranolol?

asthma

a nurse is obtaining an admission history from a client who is being evaluated for peptic ulcer disease (PUD). which of the following findings are indicative of this condition? (select all)

b. anemia c. tarry stools d. epigastric pain

A nurse in the clinic is caring for a client whose partner states the client woke up this morning and did not recognize him and did not know where she was. The client reports chills and chest pain that is worse upon inspiration which of the following actions is the nursing priority?

baseline o2 and VS

caring for a pt with cataracts. what manifestations should the nurse expect to find?

blurred vision and white pupils

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider?

bronchospasm

a nurse is providing instruction to a client who reports constipation and has a prescription for a high fiber, low fat diet. which of the following food choices by the client indicates he understand the teaching?

brown rice

a nurse in a provider's office is monitoring serum electrolytes for four older clients who take digoxin. which of the following electrolyte values increases a clients risk for digoxin toxicity?

potassium 3.4

A nurse in an assisted living facility is caring for an older adult client. The nurse should recognize that older adults have decreased absorption of which of the following? (Select all that apply.)

calcium and folic acid

nurse is teaching a client who has GERD. Which of the following should the client be instructed to limit in his diet? (Select all that apply.)

coffee tomatoes chocolate

a nurse is teaching a client who has a new prescription for digoxin to treat heart failure. which of the following instructions should the nurse include in the teaching?

contact provider if heart rate is less than 60/min

A nurse in a provider's office is reviewing lab results of a client who is being evaluated for secondary hypothyroidism. Which of the following lab findings is expected for a client who has this condition?

decreased t3

A nurse is instructing a client on the use of an IS. Which of the following statements made by the client indicates an understanding of the teaching?

deep breath and hold it before exhale

A nurse is planning to instruct a client on how to perform pursed lip breathing. Which of the following should the nurse include in the plan of care?

deep breath in nose and out mouth

A nurse is completing discharge teaching to a client who has Crohn's disease. Which of the following should be included in the teaching?

drink canned protein supplements

A nurse is collecting an admission history from a female client who has hypothyroidism. Which of the following findings should the nurse expect? (select all that apply)

dry skin hoarseness menorrhagia

A nurse is completing discharge teaching to a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching?

elevate head of bed on blocks

a nurse is providing teaching to a client who has a new prescription for digoxin. the nurse should instruct the client to monitor and report which of the following adverse effects that is a manifestations of digoxin toxicity?

fatigue anorexia diplopia

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority.

fowlers

A nurse is caring for an older adult male pt with a new dx of glaucoma. what should the nurse recognize as risk factors associated with the disease?

genetic predisposition, HTN, DM, Age

signs of needing a decrease in levothyroxine dosage

hand tremors

A nurse is reviewing the laboratory findings of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory findings is indicative of Crohn's disease? (Select all that apply.)

high ESR and WBC

A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy?

hip arthroplasty 2 weeks ago

A nurse is preparing to administer a new prescription prednisone (deltasone) to a client who has COPD. Which of the following should the nurse monitor for? (Select all)

hypokalemia fluid retention black tarry stool

A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching?

increase in HR

A nurse is providing teaching for a client who has a new diagnosis of dumping syndrome followinggastric surgery. Which of the following should be included in the teaching?

increase protein

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching?

limit fiber in diet

a nurse is providing post op teaching following cataract surgery. what statement should the nurse include in the teaching?

limit your housekeeping activities

A nurse is completing an assessment of a client who has GERD. Which of the following is anexpected finding?

loss of tooth enamel

A nurse is teaching a client who has a new diagnosis of pernicious anemia due to chronic gastritis.Which of the following should be included in the teaching?

monthly injection required

A nurse is providing discharge teaching for a client who has a prescription for furosemide (Lasix) 40 mgPO daily. What time of day should the nurse encourage the client to take this medication?

morning

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of266/147 mm Hg. The client reports a headache and states that she is seeing double. The client states thatshe ran out of her diltiazem (Cardizem) 3 days ago, and she has not been able to purchase more. Which of-the following nursing interventions should the nurse expect to perform first?

obtain IV access

A nurse is caring for a client who has atrial fibrillation and a new prescription for dabigatran to prevent development of thrombosis. Which of the following medications is prescribed concurrently to treat an adverse effect of dabigatran?

omeprazole

a nurse is caring for an older adult pt who has diabetes mellitus. the pt reports loss of peripheral vision. for which of the following is the pt at risk?

open angle glaucoma

A nurse is assessing a client who has a PE. Which of the clinical manifestations should the nurse expect to find (select all)?

pleural friction rub Petechiae Tachycardia

A nurse is providing information about capsaicin (Capsin) cream to a client who reports continuous knee pain from osteoarthritis. Which of the information should the nurse include in the discussion?

put on gloves before applying cream to different body parts

A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction?

small frequent liquid stools

A nurse is providing instructions about the use of laxatives to a client who has heart failure. The nurse should tell the client to avoid which of the following laxatives?

sodium phosphate

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease (IBD). Which of the following assessment findings is the highest priority?

sore throat

new prescription for levothyroxine teaching

take on empty stomach follow up TSH levels will be needed do not stop without providers consent

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

taking antacids several times daily

A nurse is caring for a client who had a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure?

temp elevation

A nurse is providing educational information on glucosamine to a group of clients at a health fair. Which of the following should the nurse include in the teaching?

the medication aids in the rebuilding of cartilage (RED on PP aka know this)

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?

there are portable o2 tanks

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing threespecimens. Which of the following statements by the client indicates understanding of the teaching?

this is an easy way to rule out colon cancer

A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate aprescription for which of the following medications?

vasopressin

a nurse is caring for an older adult client who has a new prescription for digoxin and takes multiple other medications. the nurse should recognize that concurrent use of which of the following medication places the client at for digoxin toxicity?

verapamil

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide(Amphojel). The nurse should advise the client to

wait 1-2 hours before taking other meds

A nurse is completing an assessment of a client's current medications. The client states she also takes gingko biloba. Which of the following medications is contraindicated for a client taking gingko biloba?

warfarin