Exam 1 ATI questions
A nurse ins monitoring a client for reperfusion following thrombotic therapy to treat acute MI. Which of the following indicators should the nurse identify to confirm reperfusion?
Ventricular dysrhythmias The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.
A nurse is caring for a client tho is undergoing treatment for HTN. Which of the following statements indicates that the client is adhering to the treatment plan?
"I never would have believed I could get used to enjoying my food without salt."
A nurse is teaching a 70 year old client about risk factors for heart failure. The client has mild asthma, diabetes, and coronary artery disease. Which of the following statements made by the client indicates an understanding of the teaching?
"My coronary artery disease is a risk factor for heart failure" CAD is a primary risk factor for the development of heart failure.
A nurse is caring for a client who is undergoing conservative treatment for DVT. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make?
"Your body has a process called fibrinolysis that will eventually dissolve the clot" Fibrinolysis is a process that breaks down a clot over time in the body. This process is a treatment option for clots that are not immediately life-threatening.
A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of MI?
Acute confusion Acute confusion is a manifestation of MI in clients age 65 or older.
A nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the clients plan of care?
Ample hydration A client who is in sickle cell crisis needs ample hydration (either IV, oral, or both) to shorten the duration of painful episodes.
A nurse on a telemetry unit is caring for a patient who has an irregular pulse. Which of the following ECG abnormalities should the nurse recognize as atrial flutter?
Atrial rate of 300/min with QRS complex of 80/min The nurse should interpret this finding as atrial flutter, which indicates a lack of conduction between the atria and ventricles. The additional atrial beats are not conducting.
A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following should the nurse expect? (Select all that apply)
Bleeding at the venipuncture site Petechiae on the chest and arms Abdominal dissension The formation of large amounts of miroemboli in the circulation depletes the body's platelets and clotting factors. As a result, uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, Petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal dissension due to internal bleeding.
A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?
Eat high-calorie foods first
A client comes to the ED in severe respiratory distress following a left-sided blunt chest trauma. The nurse notes absent breath sounds on the clients left side and tracheal shift to the right. For which of the following procedures should the nurse prepare the client?
Chest tube insertion The clients manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.
A nurse is caring for a client who reports calf pain. Which is the first action the nurse should take?
Check the affected extremity for warmth and redness The first action should be to assess the clients calf for swelling, redness, and warmth according the the nursing process. These findings can indicate DVT
A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply)
Check to determine the packed RBC's are less than 1 week old Ask another nurse to check the packed RBC's label against the medical record Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBC's are less than 1 week old; if the blood is older, the RBC's become fragile, break easily, and release potassium into the blood stream. In addition, the nurse should ask another nurse to check the packed RBC's label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBC's.
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?
Draining blood and fluid from the pleural space The nurse should inform the client that the blood and fluid tends to accumulate in the bases and the posterior areas of the pleural cavity following a lobectomy. Because of this, the lower chest tube primarily drains blood and fluid from the pleural space.
A nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumptions of which of the following foods?
Eggs The nurse should encourage the client to increase consumption of foods rich in vitamin B12, such as dairy products, animal protein, poultry, shellfish, and eggs.
A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority?
Ensure an adequate airway First action should be the airway, breathing, and circulation (ABC) approach to client care is to ensure the clients airway is adequate, as respiratory depression is a manifestation of opioid toxicity.
A nurse is reviewing the lab results of a client who has end-stage renal disease and reports fatigue. The clients hemoglobin level is 8. The nurse should expect a prescription for which of the following medications?
Erythropoietin Erythroprotein stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.
A nurse on a medical surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?
Increased coughing The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing.
A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client?
Lung cancer usually has metastasized before the client presents with symptoms The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations. This has implications for both short and long-term care options for the client
A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?
Measure the client's abdominal girth daily The nurse should measure the client's abdominal girth daily to monitor for manifestations of internal bleeding. A client who has reduced platelet count is at risk of bleeding due to delayed clotting.
A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply)
NPO status Alternative methods of communication Changes in body image Swallowing exercises
A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and MI. Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply)
Nausea and vomiting Diaphoresis and dizziness Anxiety and feeling of doom
A nurse in a providers office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary TB?
Night sweats Night sweats and fever are clinical manifestations of TB
A nurse is caring for a client who has COPD and is experiencing SOB. Which of the following actions should the nurse perform?
Place the client in an upright position Using the ABC approach to the client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction.
A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following should the nurse expect?
Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, CKD, and diarrhea.
A nurse is assessing a client who has an abdominal aortic aneurism (AAA). Which of the following findings indicates that the AAA is expanding?
Report of sudden, severe back pain AAA is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurism is extending downward and pressing on the lumbar sacral nerve roots.
A nurse is caring for a client who has COPD with pneumonia. Th nurse should monitor the client for which of the following acid-base imbalances?
Respiratory ACIDOSIS Respiratory acidosis is a common complication of COPD. It occurs because clients who have COPD are unable to exhale CO2 due to a loss of elastic recoil in the lungs.
A nurse is preparing an in-service presentation about assessing clients who are having an acute MI. What is the most common assessment finding with an acute MI?
Substernal chest pain
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the nurse expect in the clients affected extremity?
ankle swelling Swelling of the ankles is a manifestation of venous insufficiency due to poor venous return.
A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect?
increased hematocrit level Increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.
A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care?
monitor for bleeding Bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath.
A nurse is reviewing the lab results of a client who has METABOLIC ALKALOSIS. Which of the following lab values should the nurse expect?
pH 7.49 HCO3- 32 PaCO2 40 The nurse should identify these lab values reflect metabolic alkalosis. The pH values are greater than the expected reference range, and the PaCO2 is within the expected reference range. pH range (7.35-7.45) PaCO2 range (35-45) HCO3 (21-28)
