Nursing 402 – Ati Test A

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following 1. laboratory findings should the nurse expect? a. Negative urine ketones b. c. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. 2. The nurse should give the AP which of the following instructions? a. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an 3. understanding of the teaching? a. "I will monitor my blood sugar carefully because the medication increases the secretion b. of insulin." c. A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an 4. adverse reaction to this medication? a. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when 5. demonstrating crutch use. a. A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. 6. Which of the following manifestations should the nurse expect? (Select all that apply.) a. b. Non-Pitting edema c. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive 7. cough. Which of the following actions should the nurse take first? Provide hand hygiene education a. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter 8. placed. Which of the following findings indicates that the client is experiencing increased a. b. A nurse is caring for a client who is having a seizure. Which of the following interventions is the 9. nurse’s priority? Check the client's pupillary response. a. b. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should 10.A the nurse include? Take pain medication 30 min after changing the dressing. a. b. A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that 11.A apply.) An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic 12. dehydration? Respiratory rate decreased a. b. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of 13.A the following findings? a. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of 14.A the following actions? a. A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse 15.A provide? a. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when 16.A instructing the client? a. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the 17.A following actions should the nurse take first? Instruct the client to use the incentive spirometer. a. b. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an 18.A understanding of the teaching? a. "I should inform the provider if I experience an increased appetite while taking this b. medication." A nurse in a provider’s office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following 19.A client medications interacts with feverfew. a. A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to 20.A include which of the following foods that has the greatest amount of calcium in her diet? a. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of 21.A the teaching? A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference 22.A range? Bilirubin a. A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication 23.A that the client understands the teaching? "I will use a heating pad on my neck if it becomes sore during the radiation therapy." c. 24.A A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse 24.B plan to administer? a. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the 25.A nurse expect? A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the 26.A nurse include in the teaching? a. A nurse has received a change-of-shift report for a group of clients. Which of the following clients should the nurse 27.A assess first? a. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on b. a scale of 0 to 10 c. d. A client who has atopic dermatitis manifesting with scaling and excoriation of the skin e. and reports severe itching f. A client who has pneumonia manifesting with bilateral crackles and diminished breath g. sounds A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should 28.A the nurse expect? a. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the 29.A provider? a. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 30.A hr prior to cardioversion? a. A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following oxygen 31.A delivery systems should the nurse initiate to provide the highest concentration of oxygen? a. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the 33.A nurse’s priority? A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take 34.A first? Call the laboratory to obtain a stat platelet count. a. b. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the 35.A nurse expect? a. A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the 36.A teaching? Wear underwear made of nylon. a. b. A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the 37.A nurse monitor? a. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of 38.A the following actions should the nurse take first? a. a. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the 40.A nurse’s priority? Abdominal pain radiating to the right shoulder a. b. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to 41.A the provider? a. A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, 42.A which of the following items should the nurse prepare to administer first? a. A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in 43.A the plan? a. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the 44.A change? a. b. "I'm concerned I won't be able to read my blood sugar level because the screen is so c. small." d. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have e. to." A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take 45.A first? a. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed 46.A HIV treatment? a. A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the 47.A following foods should the nurse recommend the client avoid? a. A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the 48.A nurse include in the plan? a. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements 49.A should the nurse include in the teaching? a. A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mmHg, and respiratory rate 30/min. Which of the following actions should the 50.A nurse take? a. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an 51.A understanding of the teaching? A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the 52.A nurse include in the teaching? "Your constipation will be lessened as you develop a tolerance to the medication." a. b. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should 53.A the nurse include? A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following 54.A actions should the nurse take? a. Verify the client's identity by using the client's room number prior to starting the b. transfusion. a. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify which of the following findings requires further 56.A assessment? a. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing’s 57.A triad? Nuchal rigidity a. A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the 58.A nurse make? "You will need to limit your caffeine intake if you start taking sildenafil." a. b. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the 59.A nurse take? Irrigate with hydrogen peroxide solution. a. b. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the 60.A teaching? a. A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty. Which of the following actions should the nurse 61.A take? Encourage range of motion of the hip up to a 120° angle. a. b. A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing a 62.A murmur? Check the client's blood pressure manually. a. b. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic 63.A glomerulonephritis? A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse 64.A take? Tell the client to remove the incisional adhesive strips 3 days after discharge. a. b. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions 65.A should the nurse take? A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include 66.A in the teaching? A nurse in an emergency department is reviewing the provider’s prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should 67.A the nurse expect? a. A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the 68.A teaching? a. a. A nurse is assessing a client who has had plaster cast applied to their left leg 2 hours ago. Which of the following actions should the 70.A nurse take? a. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted.” Which of the following actions 71.A should the nurse take? A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following 72.A findings? Laboratory findings a. b. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is 73.A experiencing fluid volume deficit? a. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the 74.A medication? a. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following 75.A actions should the nurse take? a. A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the 76.A nurse Keep the overhead lights on in the client's bedroom while the client is sleeping. a. b. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client’s chart, which of the 77.A following findings should the nurse report to the provider? A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the 78.A nurse take? a. A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client 79.A to report? a. A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound 80.A healing? a. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of 81.A the following clients? a. A client who is having emotional difficulty accepting that they have a prosthetic leg b. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2000 kcal per day. The TPN solution has 500 kcal/L. The IV 82.A pump should be set at how many mL/hr? A nurse is teaching a class about client rights. Which of the following instructions should the 83.A nurse include? a. An unemancipated minor needs guardian consent for substance use disorder treatment. b. 84.A A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should 84.B the nurse implement? Maintain the client's bed at hip level or above. a. b. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the 85.A nurse recommend? A nurse is caring for a client 1 hour following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the 86.A affected extremity. Which of the following interventions is the nurse’s priority? A nurse is assessing a group of clients for indications of role changes. The nurse should identify which of the following clients is at risk for experiencing a role 87.A change? a. 88.A A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the 88.B client’s bedside? a.