PRACTICE ATI MISSED WITH 99
QUESTIONS AND CORRECT ANSWERS
RATED A+ NEWEST UPDATE
A nurse is planning care for a client who is having a modified radical mastectomy
of the right breast. Which of the following interventions should be included in plan
of care?
A. Instruct the client that the drain will be removed when there is 25mL of output
or less over a 24hr period
B. Assist the client ot start arm exercises 48hrs after surgery
C. Maintain the right arm in an extended position at the clients side when in bed
D. Place the client in a supine position for the first 24hr after surgery
A. The drain will remain in place for 1-3 weeks after surgery and will be removed
when there is 25 or less mL of output
A nurse is reviewing the laboratory results of a client who has AIDs and is taking
amphotericin B for a fungal infection. The nurse should identify which of the
following values is an indication of an adverse effect of the medication?
A. Potassium 4.8
B. Magnesium 1.7
C. BUN 34
D. Hematocrit 45%
C. BUN 34, Amphotericin B is nephrotoxic. An elevated BUN or creatinine level
can indicate renal impairment.
A nurse is planning care for a client who is postop following a laparotomy and has
a closed-suction drain. Which actions should the nurse take?
A. Set the wall suction to 80-100mmHg
B. Compress the drain reservoir after emptying
C. Allow the drainage to collect on a sterile gauze dressing
D. Position the drain below the bed to promote drainage
,B. Compressing the reservoir creates a vaccum that draws fluid out of the wound
thru the drain and into the reservoir
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the values should the nurse identify as a desired
outcome?
A. INR 1
B. INR 2.5
C. aPTT 45 seconds
D. aPTT 90 secs
B. INR therapeutic range is 2-3 for a client with atrial fibrillation
A nurse is checking the ECG rhythm strip for a client who has a temporary
pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex.
Which of the following actions should the nurse take?
A. Document the depolarization has occurred
B. Increase the pacemakers voltage
C. Decrease the pacemaker's sensitivity
D. Check the placement of ECG leads
A. When a pacing stimulus is delivered to the ventricle a pacemaker artifact
appears as a spike on the ECG rhythm strip. The spike should be followed by a
QRS complex which indicates depolarization
A nurse is providing teaching to a client who has hypertension and a new
prescription for verapamil. Which of the following should be included in the
teaching?
A. Take this medication on an empty stomach
B. Eczema is an immediate expected adverse effect of this medication
C. Increase fiber intake to avoid constipation
D. Monitor your blood pressure monthly
C. The nurse should instruct the client that constipation is an adverse effect of
verapamil.
, A nurse is providing discharge teaching about infection prevention to a client who
has AIDS. Which statement indicates an understanding of the teaching?
A. I will eat a salad at least once a day to increase my intake of vitamin K
B. I can work in my flower garden as long as I wear gardening gloves to cover my
skin
C. I will no longer floss my teeth after brushing
D. I can sip on
C. Flossing can cause gum inflammation which can result in infection
A nurse is providing teaching to a client who has anemia and a new prescription for
an oral iron supplement. Which of the following statements by the client indicates
an understanding of the teaching?
A. I will take my iron with a glass of milk
B. I will take an antacid with my iron
C. I will limit my intake of red meat
D. I will eat more high fiber foods
D. Constipation is a common adverse effect of oral iron suppliments
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. Which should be reported as an adverse effect of this
medication?
A. Decreased heart rate
B. Crackles heard on auscultation
C. Increased urinary output
D. Decreased deep tendon reflexes
B. Mannitol is an osmotic diuretic that can leave the vascular system at the
capillary site, which can result in edema. Crackles is a manifestation of pulmonary
edema
A nurse is caring for a client who is having tonic clonic seizure while in bed and
has become cyanotic. Which of the following actions should the nurse take?
(SATA)
A. Restrain the client
B. Prepare to suction the client's airway
C. Insert a tongue blade
QUESTIONS AND CORRECT ANSWERS
RATED A+ NEWEST UPDATE
A nurse is planning care for a client who is having a modified radical mastectomy
of the right breast. Which of the following interventions should be included in plan
of care?
A. Instruct the client that the drain will be removed when there is 25mL of output
or less over a 24hr period
B. Assist the client ot start arm exercises 48hrs after surgery
C. Maintain the right arm in an extended position at the clients side when in bed
D. Place the client in a supine position for the first 24hr after surgery
A. The drain will remain in place for 1-3 weeks after surgery and will be removed
when there is 25 or less mL of output
A nurse is reviewing the laboratory results of a client who has AIDs and is taking
amphotericin B for a fungal infection. The nurse should identify which of the
following values is an indication of an adverse effect of the medication?
A. Potassium 4.8
B. Magnesium 1.7
C. BUN 34
D. Hematocrit 45%
C. BUN 34, Amphotericin B is nephrotoxic. An elevated BUN or creatinine level
can indicate renal impairment.
A nurse is planning care for a client who is postop following a laparotomy and has
a closed-suction drain. Which actions should the nurse take?
A. Set the wall suction to 80-100mmHg
B. Compress the drain reservoir after emptying
C. Allow the drainage to collect on a sterile gauze dressing
D. Position the drain below the bed to promote drainage
,B. Compressing the reservoir creates a vaccum that draws fluid out of the wound
thru the drain and into the reservoir
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the values should the nurse identify as a desired
outcome?
A. INR 1
B. INR 2.5
C. aPTT 45 seconds
D. aPTT 90 secs
B. INR therapeutic range is 2-3 for a client with atrial fibrillation
A nurse is checking the ECG rhythm strip for a client who has a temporary
pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex.
Which of the following actions should the nurse take?
A. Document the depolarization has occurred
B. Increase the pacemakers voltage
C. Decrease the pacemaker's sensitivity
D. Check the placement of ECG leads
A. When a pacing stimulus is delivered to the ventricle a pacemaker artifact
appears as a spike on the ECG rhythm strip. The spike should be followed by a
QRS complex which indicates depolarization
A nurse is providing teaching to a client who has hypertension and a new
prescription for verapamil. Which of the following should be included in the
teaching?
A. Take this medication on an empty stomach
B. Eczema is an immediate expected adverse effect of this medication
C. Increase fiber intake to avoid constipation
D. Monitor your blood pressure monthly
C. The nurse should instruct the client that constipation is an adverse effect of
verapamil.
, A nurse is providing discharge teaching about infection prevention to a client who
has AIDS. Which statement indicates an understanding of the teaching?
A. I will eat a salad at least once a day to increase my intake of vitamin K
B. I can work in my flower garden as long as I wear gardening gloves to cover my
skin
C. I will no longer floss my teeth after brushing
D. I can sip on
C. Flossing can cause gum inflammation which can result in infection
A nurse is providing teaching to a client who has anemia and a new prescription for
an oral iron supplement. Which of the following statements by the client indicates
an understanding of the teaching?
A. I will take my iron with a glass of milk
B. I will take an antacid with my iron
C. I will limit my intake of red meat
D. I will eat more high fiber foods
D. Constipation is a common adverse effect of oral iron suppliments
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. Which should be reported as an adverse effect of this
medication?
A. Decreased heart rate
B. Crackles heard on auscultation
C. Increased urinary output
D. Decreased deep tendon reflexes
B. Mannitol is an osmotic diuretic that can leave the vascular system at the
capillary site, which can result in edema. Crackles is a manifestation of pulmonary
edema
A nurse is caring for a client who is having tonic clonic seizure while in bed and
has become cyanotic. Which of the following actions should the nurse take?
(SATA)
A. Restrain the client
B. Prepare to suction the client's airway
C. Insert a tongue blade
