NU410 Exam 4 ATI Questions With
Complete Answers
A nurse on a medical-surgical unit is caring for a group of clients. The nurse
should notify the rapid response tea for which of the following clients?
A.) Client who has a pressure injury of the right heel whose blood glucose is 300
mg/dL
B.) Client who reports right calf pain and shortness of breath
C.) Client who has blood on a pressure dressing in the femoral area following a
cardiac catheterization
D.) Client who has dark red coloration of left toes and absent pedal pulse -
ANSWER B.) Client who reports right calf pain and shortness of breath
The nurse should identify that the client is at risk for respiratory arrest due to a
possible embolism. The nurse should call the rapid response team because the
manifestations can indicate the beginning of a rapid decline in the client's
condition.
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply.)
A.) Induce vomiting
B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
D.) Administer syrup of ipecac
E.) Infuse IV fluids - ANSWER B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
E.) Infuse IV fluids
A nurse in the emergency department is caring for a client who fell through the
ice on a pond and is unresponsive and breathing slowly. Which of the following
actions should the nurse take? (Select all that apply.)
A.) Remove wet clothing
B.) Maintain normal room temperature
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108 degrees
fahrenheit)
, E.) Infuse warmed IV fluids - ANSWER A.) Remove wet clothing
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108 degrees
fahrenheit)
E.) Infuse warmed IV fluids
A nurse is reviewing the common emergency management protocol for clients
who has asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A.) Perform defibrillation
B.) Prepare for transcutaneous pacing
C.) Administer IV epinephrine
D.) Elevate the client's lower extremities - ANSWER C.) Administer IV
epinephrine
Epinephrine increases HR, improves CO, and promotes bronchodilation
A nurse in the emergency department is assessing a client who is unresponsive.
The client's partner states, "He was pulling weeds in the yard and slumped to
the ground." Which of the following techniques should the nurse use to open the
client's airway?
A.) Head-tilt, chin-lift
B.) Modified jaw thrust
C.) Hyperextension of the head
D.) Flexion of the head - ANSWER A.) Head-tilt, chin-lift
The nurse should open the client's airway by the head-tilt, chin-lift because the
client is unresponsive without suspicion of trauma.
A nurse is caring for a client who has a prescription for an afterload-reducing
medication. The nurse should identify that this medication is administered for
which of the following types of shock?
A.) Cardiogenic
B.) Obstructive
C.) Hypovolemic
D.) Distributive - ANSWER A.) Cardiogenic
Identify that a prescription to reduce afterload will allow the heart to pump more
effectively, which is needed for the client who has cardiogenic shock.
A nurse is planning care for a client who has septic shock. Which of the
following actions is the priority for the nurse to take?
A.) Maintain adequate fluid volume with IV infusions
B.) Administer antibiotic therapy
C.) Monitor hemodynamic status
D.) Administer vasopressor medication - ANSWER B.) Administer antibiotic
therapy
Complete Answers
A nurse on a medical-surgical unit is caring for a group of clients. The nurse
should notify the rapid response tea for which of the following clients?
A.) Client who has a pressure injury of the right heel whose blood glucose is 300
mg/dL
B.) Client who reports right calf pain and shortness of breath
C.) Client who has blood on a pressure dressing in the femoral area following a
cardiac catheterization
D.) Client who has dark red coloration of left toes and absent pedal pulse -
ANSWER B.) Client who reports right calf pain and shortness of breath
The nurse should identify that the client is at risk for respiratory arrest due to a
possible embolism. The nurse should call the rapid response team because the
manifestations can indicate the beginning of a rapid decline in the client's
condition.
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply.)
A.) Induce vomiting
B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
D.) Administer syrup of ipecac
E.) Infuse IV fluids - ANSWER B.) Instill activated charcoal
C.) Perform a gastric lavage with aspiration
E.) Infuse IV fluids
A nurse in the emergency department is caring for a client who fell through the
ice on a pond and is unresponsive and breathing slowly. Which of the following
actions should the nurse take? (Select all that apply.)
A.) Remove wet clothing
B.) Maintain normal room temperature
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108 degrees
fahrenheit)
, E.) Infuse warmed IV fluids - ANSWER A.) Remove wet clothing
C.) Apply warm blankets
D.) Use of rapid rewarming water 40-42 degrees celsius (104-108 degrees
fahrenheit)
E.) Infuse warmed IV fluids
A nurse is reviewing the common emergency management protocol for clients
who has asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
A.) Perform defibrillation
B.) Prepare for transcutaneous pacing
C.) Administer IV epinephrine
D.) Elevate the client's lower extremities - ANSWER C.) Administer IV
epinephrine
Epinephrine increases HR, improves CO, and promotes bronchodilation
A nurse in the emergency department is assessing a client who is unresponsive.
The client's partner states, "He was pulling weeds in the yard and slumped to
the ground." Which of the following techniques should the nurse use to open the
client's airway?
A.) Head-tilt, chin-lift
B.) Modified jaw thrust
C.) Hyperextension of the head
D.) Flexion of the head - ANSWER A.) Head-tilt, chin-lift
The nurse should open the client's airway by the head-tilt, chin-lift because the
client is unresponsive without suspicion of trauma.
A nurse is caring for a client who has a prescription for an afterload-reducing
medication. The nurse should identify that this medication is administered for
which of the following types of shock?
A.) Cardiogenic
B.) Obstructive
C.) Hypovolemic
D.) Distributive - ANSWER A.) Cardiogenic
Identify that a prescription to reduce afterload will allow the heart to pump more
effectively, which is needed for the client who has cardiogenic shock.
A nurse is planning care for a client who has septic shock. Which of the
following actions is the priority for the nurse to take?
A.) Maintain adequate fluid volume with IV infusions
B.) Administer antibiotic therapy
C.) Monitor hemodynamic status
D.) Administer vasopressor medication - ANSWER B.) Administer antibiotic
therapy
