Exam 3 ATI Questions

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following finding should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. NEC

B. Retinopathy

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent Neural tube defect? A. Take multivitamin daily B. Decrease consumption of mercury C. Increase dairy consumption D. Begin taking a folic acid supplement

D. Begin taking a folic acid supplement

A nurse is showing a client who has R sided HF an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the R atrium? A. Right coronary artery B. Left carotid artery C. Aorta D. Superior vena cava

D. Superior vena cava

A nurse is orienting a new nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective? A. Performs range of motion on the infants hips B. Maintains a dry dressing over the sac C. Takes an axillary temperature D. Places the infant in a side-lying position

C. Takes an axillary temperature - Rectal temperatures should be avoided in infants who have spina bifida due to the risk for irritation and rectal prolapse.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for CAD? A. Hypothyroidism B. HTN C. Diabetes Mellitus D. Hyperlipidemia E. Tobacco smoking

B. HTN C. Diabetes Mellitus D. Hyperlipidemia E. Tobacco smoking

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. 5th intercostal space just medial to the midclavicular line B. 2nd intercostal space to the left of the sternum C. 5th intercostal space to the left of the sternum D. 2nd intercostal space to the right of the sternum

D. 2nd intercostal space to the right of the sternum - the aortic valve is located in the 2nd intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is assessing a client who has R sided HF. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema

D. Dependent edema

A nurse is developing a plan of care for a client who has GERD. The nurse should plan to monitor the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

A. Aspiration

A nurse is caring for a client who has a MI 2 hrs ago and is receiving alteplase. Which of the following findings should the nurse identify as an adverse effect of receiving this medication? A. Bleeding B. Increased clot formation C. SOB D. Blockage of the central venous catheter

A. Bleeding

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprungs disease D. Crohns disease

A. Celiac disease

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check vital signs B. Request a dietitian consult C. Suggest that the client rests before eating the meal D. Request an order for an antiemetic

A. Check vital signs - It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

A nurse is caring for a client who had a MI 5 days ago. The patient reports a sudden onset of SOB, frothy pink sputum. The nurse expect to hear what breath sounds? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction Rub

A. Coarse crackles - patient who had a recent Mi is at risk for Left sided heart failure

A nurse is admitting a client who is experiencing an exacerbation of HF. At which of the following times should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge

A. During the admission process

A nurse is planning care for an infant who has HF. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? Select all A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi upright during feedings E. Provide gavage feeding if RR exceeds 80

B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi upright during feedings E. Provide gavage feeding if RR exceeds 80 - infants should feed every 3 hours

A nurse is assessing a client who has left sided HF. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. JVD D. Hepatomegaly

B. Crackles in the lung bases

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect? A. Nystagmus B. Dilated pupils C. Hypersomnia D. Depress

B. Dilated pupils - Dilated pupils are a finding of cocaine intoxication due to the stimulation of the sympathetic nervous system.

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart Failure D. Pulmonary edema

B. Dysrhythmias - dysrhythmias are the most common cause of death following MI. Therefore, nurses should monitor clients ECGs carefully for dysrhythmias and report and treat them immediately

A nurse is teaching a client who has iron deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? A. Lentils B. Avocados C. Cabbage D. Broccoli

A. Lentils

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. Maintain the integrity of the sac B. Promote maternal - infant bonding C. Educate the parents about the defect D. Provides age-appropriate stimulation

A. Maintain the integrity of the sac - Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.

A nurse is planning care for a suspect failure to thrive 10-month-old. Which of the following interventions should the nurse include in the plan of care? A. Observe the parent's actions when feeding the child B. Maintain a detailed record of food and fluid intake C. Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during feedings

A. Observe the parent's actions when feeding the child B. Maintain a detailed record of food and fluid intake

A nurse is assessing a newborn for manifestations of a PDA. Which of the following findings should the nurse expect? A. Cyanosis with crying B. Systolic murmur C. Weak pulses D. Chronic hypoxemia

B. Systolic murmur

A nurse is preparing an in-service presentation about the management of MI. Death following MI is often a result of which of the following complications? A. cardiogenic shock B. dysrhythmias C. Heart failure D. Pulmonary edema

B. dysrhythmias - most common cause of death following MI

A nurse is caring for an infant who has TOF and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the in a knee - chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen

A. Place the in a knee - chest position - this position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery.

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following lab results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 B. Digoxin level .7 C. Hemoglobin 9.8 D. Calcium 8.0

A. Potassium 2.8 - flattened T wave or the developmental of U waves is indicative of a low potassium

Patient has GERD. The nurse should expect the client to report which of the following manifestations? A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss

A. Regurgitation B. Nausea C. Belching D. Heartburn

A nurse in a MED-SURg unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain - a manifestation of a PE is sudden chest pain that is sharp and stabbing

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse exepect? A. Muscle aches and chills B. Fatigue and depression C. Anxiety and diaphoresis D. Arrhythmia and respiratory depression

C. Anxiety and diaphoresis - Alcohol withdrawal symptoms usually occur within hours of the client's last drink, and symptoms intensify over 1 to 3 days after the last drink. - Early signs of withdrawal include anxiety, diaphoresis, irritability, mood swings, tremors, dilated pupils, tachycardia, hypertension, anorexia and insomnia. Alcohol withdrawal requires medical attention to safely manage the client and avoid death.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? A. Pruritus B. Hypertension C. Bradykinesia D. Xerostomia

C. Bradykinesia - The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight Gain C. Breathlessness D. Distended abdomen

C. Breathlessness - Manifestation of left - sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion

A nurse is caring for a client who has wenicke-korsakoff syndrome due to alcohol use disorder. Which of the following findings should the nurse expect? A. Increased arousal B. Arrhythmias C. Confusion D. Esophageal pain

C. Confusion - a client with this syndrome should exhibit neurological and cognitive manifestations due to thiamine deficiency

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain that increases when sitting upright

C. Dyspnea with hiccups

A nurse is caring for a client who reports crushing chest pain. The nurse reviews the client's ECG results and notes ST changes. Which of the following medications should the nurse administer? A. Simvastatin B. Furosemide C. Nitroglyercin D. Slidenafil

C. Nitroglycerin - treats angina

A nurse is assessing a 2 month old who has VSD. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8kg B. Heart rate of 125 C. Soft fontanel D. Systemic murmur

A. Weight gain of 1.8kg - indicates increased fluid and worsening of the child's heart failure

A nurse is assessing a 6 month infant who has a cardiax catherization with right femoral entry to diagnose a possible CHD. Which of the following findings should the nurse report to the provider? A. cool toes on the right foot B. Weak pulses on the feet C. Positive babinski D. erythema on the right foot

A. cool toes on the right foot

A nurse is providing teaching to the parents of an infant who has HF and a new RX of digoxin. Which of the following pieces of information should the nurse include? A. withhold the medication if the infant's HR is less than 110 B. Mix the medication with formula C. Expect to vomit D. Double the dose if the patient has edema

A. withhold the medication if the infant's HR is less than 110

A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. Oranges and Tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole wheat and beans

A. Oranges and Tomatoes - decrease high acid foods such as alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint

A nurse on a MED-Surg unit is caring for a client who is postoperative following hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea - PE have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs

A nurse is providing teaching to a client with HF about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the patient B. The emphasis the provider places C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

A. The involvement of the patient

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent Ductus arteriosus

A. Transposition of the great arteries - An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fatal hear rate. Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal Head compression C. Fetal ventricular septal defect D. Umbilical cord compression

A. Uteroplacental insufficiency

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg in 1 day B. Pitting edema C. Client reported of a cough D. DNP level of 100

A. Weight gain of 1 kg in 1 day - weight gain indicates that the client is retaining fluid and is at risk of fluid volume overload

a nurse is assessing a 2 month old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

A. Weight gain of 1.8 kg - A 4lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.

A nurse is monitoring a client who has HF related to mitral stenosis. The client reports SOB on exertion. Which of the following conditions should the nurse expect? A. Increased CO B. Increase Pulmonary congestion C. Decreased left atrial pressure D. Decrease pulmonary artery pressure

B. Increase Pulmonary congestion - Defect in the valve, the l atrial pressure rises and the l atrium dilates. The increased pressure results in a backflow of blood from the l atrium to the pulmonary vein and into the lungs resulting in pulmonary congestion

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome? A. History of asthma B. Large waist size C. Hypotension D. Hypoglycemia

B. Large waist size - Central obesity due to excessive abdominal fat is a risk factor for metabolic syndrome. Metabolic syndrome increases the risk for the development of diabetes and coronary artery disease.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic Murmur B. Murmur at the left sternal border C. Cyanosis that increase with crying D. Widened pulse pressure

B. Murmur at the left sternal border - a hole in the septal wall between the ventricles is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.

A nurse is giving a presentation about preventing DVT. Which of the following should the nurse include as a risk factor for this disorder? A. BMI of 20 B. Oral Contraceptive use C. HTN D. High Calcium intake E. Immobility

B. Oral Contraceptive use E. Immobility

A nurse is caring for an infant who has congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? A. Coarctation of the aorta B. Patent ductus arteriosus C. Tetralogy of Fallot D. Tricuspid atresia

B. Patent ductus arteriosus - With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs.

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. Which of the following is an expect finding? A. Family history of Alzheimer's disease B. Personal hx of alcohol use disorder C. Undergoing current treatment for HIV D. Current rehabilitation for opiate addiction

B. Personal hx of alcohol use disorder - Wernicke-Korsakoff syndrome is a type of secondary dementia as a result of thiamine deficiency that is commonly associated with alcohol use disorder. The syndrome results in confusion and memory loss and is treated with thiamine replacement therapy.

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority? A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Confronting the use of denial and other defense mechanisms D. Educating the client about the consequences of alcohol misuse

B. Providing for adequate hydration and rest - Providing for the client's physical needs should be the nurse's priority. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.

A nurse is assessing a school age child who has celiac disease. Which of the following findings should the nurse expect? A. Elevated sweat chloride B. Steatorrhea C. Clubbing of the fingers D. Jaundice

B. Steatorrhea

a nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

C. Palpate the abdomen for bladder distension - neurogenic bladder is a common complication of spina bifida

A nurse is teaching the parents of an infant who has GER. Which of the following instructions about the feeding therapies should the nurse recommend? A. Apply the infants diaper snugly prior to feeding B. Administer nasogastric feedings C. Thicken feedings with rice cereal D. Place the infant in a later position for 1 hour after feeding

C. Thicken feedings with rice cereal - Thickening the food decreases infants risk of GER and promote weight gain

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias - the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the hearts electrical system.

A nurse is assessing a client who has HF and is receiving digoxin. Which of the following findings should indicate to the nurse the client is experiencing digoxin toxicity? A. Suppression of dysrhythmias B. Increased AV conduction C. Visual disturbances D. Weight gain

C. Visual disturbances - recognize that N, V, abdominal discomfort, fatigue, and vision changes are common manifestations of digoxin toxicity

A nurse is providing teaching to a client with a new DX of HF who has an RX for furosemide. Which of the following statements should the nurse include in the teaching? A. You can take Ibuprofen for HA B. You may see an increase in swelling in the lower extremities C. You should eat foods rich in potassium while on this medication D. You should take this medication at bedtime

C. You should eat foods rich in potassium while on this medication - medication is a diuretic that depletes potassium, sodium, chloride, Mg 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. raisins B. black tea C. black beans D. whole milk

C. black beans -The nurse should recommend that the client eat dried fruits, such as raisins, to increase iron intake. However, a small box (1.5 oz) of raisins contains only 0.81 mg of iron. That is why black beans are correct

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000 B. WBC 4,000 C. Thyroid stimulating hormone 7.0 D. RBC 6.8 million

D. RBC 6.8 million - a child who has TOF experiences cyanosis; therefore, the body responds by increasing RBC production in an attempt to supply oxygen to all body parts.

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding B. Insert an orogastric tube for decompression of the stomach C. Place the newborn in Trendelenburg position D. Maintain oxygen saturations between 93% and 95%.

D. Maintain oxygen saturations between 93% and 95%. - Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

A nurse assesses a client who has been taking simvastatin to treat hyperlipidemia. Which of the following statements by the client indicates an adverse effect of the medication that should be reported to the provider immediately? A. I have had occasional constipation B. I have had some gas C. My head has been hurting for some days D. My legs feel weak and achy

D. My legs feel weak and achy

A nurse is caring for a client who is having difficult with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum

D. Cerebellum

A nurse is providing teaching for a client who has a new dx 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 - Exertion and anxiety can trigger the pain of angina, unless it is variant angina, which occurs at rest.

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back discomfort

D. Lower back discomfort - AAA involves a widening , stretching or ballooning of the aorta. Back pain and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerves.

A nurse is reviewing the morning labs for an infant who is on digoxin and furosemide for the treatment of HF. Which of the following findings should the nurse report to the provider? A. Sodium 140 B. Calcium 10.2 C. Chloride 100 D. Potassium 3.2

D. Potassium 3.2 - below the expected range for an infant

A nurse is reviewing the progress notes for a client who has HF. The provider notes some improvement in the clients CO. The nurse should understand that CO reflects which of the following physiologic parameters? A. The % of blood the ventricles pump during each beat B. The amount of blood the L ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume