PCC II Exam 1 ATI Remediation
A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol
Correct Answer: A. Erythropoietin Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.
A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? A. Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity
Correct Answer: A. Increased hematocrit level The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume.
A nurse is reviewing a client's repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory results should the nurse review? A. Prothrombin time B. WBC count C. Platelet count D. Hematocrit
Correct Answer: A. Prothrombin time The nurse should review the client's prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat acute clotting disorders. The desired effect is a decrease in the prothrombin time.
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? A. Turn the client from side to side B. Elevate the height of the dialysate bag C. Lower the head of the client's bed D. Advance the catheter approximately 2.5 cm (1 in) further
Correct Answer: A. Turn the client from side to side The nurse should assist the client in turning from side to side to facilitate the removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter.
A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade
Correct Answer: A. Acidosis Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1°C (1.8°F) per hour.
A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? A. Calcium B. Phosphorous C. Potassium D. Sodium
Correct Answer: A. Calcium A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary calcium.
While participating in a community health fair, a nurse is providing information to a client who has a blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take? A. Give the client a written record of his BP to bring to his provider B. Encourage the client to go to the nearest emergency department C. Instruct the client to follow-up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension
Correct Answer: A. Give the client a written record of his BP to bring to his provider Since this client has an elevated BP reading from a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.
A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia
Correct Answer: A. Hypokalemia Furosemide can cause the loss of potassium, sodium, calcium, and magnesium. Manifestations of hypokalemia can include shallow respirations, muscle weakness, lethargy, and ectopic heartbeats.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure
Correct Answer: B. Increased pulmonary congestion Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.
A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? A. Allergy to egg products B. Vomiting and diarrhea for the last 6 hr C. Serum potassium of 3.6 mEq/L D. Serum creatinine of 1.2 mg/dL
Correct Answer: B. Vomiting and diarrhea for the last 6 hr Vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.
A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain." B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent." D. "It seems as though you have really had a rough time these past few weeks."
Correct Answer: C. "It sounds like your pain is intermittent." This response by the nurse reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message.
A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation
Correct Answer: C. Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator
Correct Answer: C. Hearing aids A client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing aids, so they should be removed prior to the client undergoing MRI.
A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? A. Decreased white blood cell (WBC) count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level
Correct Answer: C. Increased serum lipase level Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum
Correct Answer: C. Insert the tip of the tubing 8 cm (3.1 in) The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa.
A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? A. "You will be NPO for 8 hr following the procedure." B. "An allergy to shellfish is a contraindication to this procedure." C. "You will need to be on bed rest following the procedure." D. "A creatinine clearance is needed prior to the procedure."
Correct Answer: C. "You will need to be on bed rest following the procedure." A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney. The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hours following the procedure to reduce the risk of bleeding. The nurse can elevate the head of the bed.
A nurse is preparing a client for a bone-marrow biopsy. Which of the following pieces of information should the nurse include in preoperative teaching? A. "You'll receive heavy sedation, so you might even sleep during the procedure." B. "You'll have to lie on your back throughout the procedure." C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." D. "Expect the procedure to take about an hour."
Correct Answer: C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow." The nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow as well as some discomfort from the rotation of the needle into the bone.
A nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit
Correct Answer: C. Auscultate blood pressure for pulsus paradoxus The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations
Correct Answer: C. Substernal chest pain Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.
A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole
Correct Answer: C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.
During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"
Correct Answer: D. "Can you tell me what the pain felt like and show me exactly where it was?" Using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority question for evaluating the client's pain is to quantify its characteristics, onset, duration, surrounding events, and location. This will help the nurse determine what action to take next.
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids
Correct Answer: D. Clear liquids Clear liquids, such as water or broth, can be given for the first oral feeding but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.
A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of nonadherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials D. Help the client identify ways that these changes will result in positive personal outcomes
Correct Answer: D. Help the client identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.
A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse provide? A. "It's too soon to worry about something that might not happen." B. "Breast cancer tends to metastasize to the stomach." C. "Metastasis is unlikely since we detected your cancer early." D. "Breast cancer tends to metastasize to the bones."
Correct Answer: D. "Breast cancer tends to metastasize to the bones." Common sites of breast cancer metastasis are the bones, lungs, brain, and liver.
A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures? A. Exploratory laparotomy B. Double-contrast barium enema C. Magnetic resonance imaging D. Colonoscopy
Correct Answer: D. Colonoscopy A colonoscopy requires the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. It can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of bleeding.
A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals
Correct Answer: D. Maintain a supine position after meals The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper gastrointestinal tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension.
A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin
Correct Answer: D. Pepsin Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body.
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 findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest and arms D. Flushed, dry skin E. Abdominal distension
Correct Answers: B. Bleeding at the venipuncture site C. Petechiae on the chest and arms E. Abdominal distension The formation of large amounts of microemboli 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 distension due to internal bleeding.
A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include in the teaching? (Select all that apply.) A. "Take your temperature twice each day." B. "You may return to school if you feel strong enough." C. "It is important to wear shoes always." D. "Clean your toothbrush weekly with isopropyl alcohol." E. "Avoid using tampons."
Correct Answers: A. "Take your temperature twice each day." C. "It is important to wear shoes always." E. "Avoid using tampons." Clients who are postoperative from bone marrow transplants are immunosuppressed and should continually monitor for manifestations of infection. A temperature that is greater than 38°C (100°F) should be reported immediately to the provider. The client should wear shoes to prevent injury and decrease the risk of infection. The use of tampons is discouraged because they can disrupt the mucosal layer of the vagina and may support the growth of bacteria if left in place for too long.
A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? (Select all that apply.) A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." C. "You'll feel a cool sensation after the injection of the dye." D. "You'll have to keep your leg straight after the procedure." E. "You'll have to limit the amount of fluid you drink for the first 24 hr." Check Answer Question Feedback Close Explanation
Correct Answers: A. "You'll have to lie flat for several hours after the procedure." B. "You'll receive medication to relax you before the procedure." D. "You'll have to keep your leg straight after the procedure." Depending on the provider's prescription, the client should remain flat or with the head of the bed elevated to no more than 30° for 2 to 6 hours after the procedure. The amount of time depends on the type of closure device the provider uses. The client will receive a mild sedative for relaxation and comfort prior to the procedure. A soft knee brace can help keep the client from bending the knee after the procedure.
A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply.) A. Nausea and vomiting B. Diaphoresis and dizziness C. Chest and left arm pain that subsides with rest D. Anxiety and feelings of doom E. Bounding pulse and bradypnea
Correct Answers: A. Nausea and vomiting B. Diaphoresis and dizziness D. Anxiety and feelings of doom Nausea, vomiting, epigastric distress, diaphoresis (sweating), dizziness, fatigue, anxiety, and feelings of doom and fear are common manifestations of MI.
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.) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hr period D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride
Correct Answers: B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. In addition, the nurse should ask another nurse to check the packed RBCs 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 lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs.
