ATI comprehensive predictor STUDY THIS
ONE
. The nurse will intervene if a client develops cor pulmonale, or right-sided heart failure. would
expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4. twitching of extremities. - ANS-3
. Two RNs, one LPN/LVN, and one nursing assistant make up the nursing team. assistant.
The nurse should consider the assignments appropriate if the
nursing assistant is assigned to care for
1. a client with Alzheimer's requiring assistance with feeding.
2. An osteoporosis patient who complained of pain when urinating. 3. A patient who has
scleroderma receiving food through a tube. 4. a client with cancer who has Cheyne-Stokes
respirations. - ANS-1
A 23-year-old man is admitted with a subdural hematoma and cerebral
edema after a motorcycle accident. Which of the following signs should you look for? the nurse
expect to see INITIALLY?
1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Seizures of great severity. 4. Decreased level of consciousness. - ANS-4
A 23-year-old woman at 32-weeks gestation is seen in the outpatient
clinic. Which of the following findings, if assessed by the nurse, would
indicate a possible complication?
1. The client's urine test is positive for glucose and acetone.
2. The client has 1+ pedal edema in both feet at the end of the day.
3. The client complains of an increase in vaginal discharge.
4. The client says she feels pressure against her diaphragm when the baby moves. - ANS-1
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. chloride of potassium for intravenous administration. 2. Calcium gluconate for IV
administration.
3. Tracheostomy set-up.
4. Suction equipment. - ANS-1
A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my
breasts." Which of the following responses by the nurse is BEST?
, 1. "You are seeing things that aren't real."
2. "Why don't we go make some fudge."
3. "You are experiencing a side effect of Haldol."
4. "I'll contact your physician to change your medication." - ANS-3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complains of constipation.
3. The dialysate outflow is cloudy.
4. There is blood-tinged fluid around the intra-abdominal catheter. - ANS-3
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile.
Which of the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) Use a phenol solution to clean the clients' room's contaminated surfaces. d) have family
members wear a gown and gloves when visiting - ANS-D
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day.
To ensure the client's safety while walking in the halls, the nurse should do which of the
following?
1. Administer PRN haloperidol (Haldol) to decrease the need to walk.
2. Assess the client's gait for steadiness.
3. In a geriatric chair, restrain the client. 4. Administer PRN lorazepam (Ativan) to provide
sedation. - ANS-2
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client's diet?
1. Protein.
2. Fats.
3. Carbohydrates.
4. Magnesium. - ANS-1
A client has a new prescription for spironilactone (aldactone). Which of the following laboratory
values should the nurse use to notify the provider and withhold the morning dose? ANS-serum
potassium 5.2 If a client has a prescription for valproic (Depakote), which of the following
laboratory values should the nurse expect to monitor? ANS-thrombocytes, amylase count, and
liver function test A client is admitted with a diagnosis of acute appendicitis. When assessing
the abdomen, the nurse would expect to find rebound tenderness at which location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant - ANS-D
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
, 2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture. - ANS-4
A client is given morphine 6 mg IV push for postoperative pain.
Following administration of this drug, the nurse observes the following:
pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the
following nursing actions is MOST appropriate?
1. Allow the client to sleep undisturbed.
2. Administer oxygen via facemask or nasal prongs.
3. Administer naloxone (Narcan).
4. Place epinephrine 1:1,000 at the bedside. - ANS-3
A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour. - ANS-4
A client is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine
that the medication is appropriate if the client displays which of the
the following symptoms? 1. Agitation and decreased level of consciousness.
2. Lethargy and decreased respiratory rate.
3. Restlessness and increased heart rate.
4. Hostility and increased blood pressure. - ANS-3
A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evaluate the client's distal pulses on the affected side. - ANS-1
a client should receive a dose of flumazenil ( romazicon) to treat symptoms of -
ANS-benzodiazepine overdose
a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and
pramipexole ( Mirapex) for which of the following should the nurse monitor this client -
ANS-orthostatic hypotension
a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking
multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid
ibuprofen. why or why not ? - ANS-what , if any is the appropriate action for the nurse to take
NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly
leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should
notify the provider of client headache and ibuprofen us
A client with a peptic ulcer had a partial gastrectomy and vagotomy
(Billroth I). In planning the discharge teaching, the client should be
ONE
. The nurse will intervene if a client develops cor pulmonale, or right-sided heart failure. would
expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4. twitching of extremities. - ANS-3
. Two RNs, one LPN/LVN, and one nursing assistant make up the nursing team. assistant.
The nurse should consider the assignments appropriate if the
nursing assistant is assigned to care for
1. a client with Alzheimer's requiring assistance with feeding.
2. An osteoporosis patient who complained of pain when urinating. 3. A patient who has
scleroderma receiving food through a tube. 4. a client with cancer who has Cheyne-Stokes
respirations. - ANS-1
A 23-year-old man is admitted with a subdural hematoma and cerebral
edema after a motorcycle accident. Which of the following signs should you look for? the nurse
expect to see INITIALLY?
1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Seizures of great severity. 4. Decreased level of consciousness. - ANS-4
A 23-year-old woman at 32-weeks gestation is seen in the outpatient
clinic. Which of the following findings, if assessed by the nurse, would
indicate a possible complication?
1. The client's urine test is positive for glucose and acetone.
2. The client has 1+ pedal edema in both feet at the end of the day.
3. The client complains of an increase in vaginal discharge.
4. The client says she feels pressure against her diaphragm when the baby moves. - ANS-1
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. chloride of potassium for intravenous administration. 2. Calcium gluconate for IV
administration.
3. Tracheostomy set-up.
4. Suction equipment. - ANS-1
A 59-year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my
breasts." Which of the following responses by the nurse is BEST?
, 1. "You are seeing things that aren't real."
2. "Why don't we go make some fudge."
3. "You are experiencing a side effect of Haldol."
4. "I'll contact your physician to change your medication." - ANS-3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an
intervention by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complains of constipation.
3. The dialysate outflow is cloudy.
4. There is blood-tinged fluid around the intra-abdominal catheter. - ANS-3
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile.
Which of the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) Use a phenol solution to clean the clients' room's contaminated surfaces. d) have family
members wear a gown and gloves when visiting - ANS-D
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day.
To ensure the client's safety while walking in the halls, the nurse should do which of the
following?
1. Administer PRN haloperidol (Haldol) to decrease the need to walk.
2. Assess the client's gait for steadiness.
3. In a geriatric chair, restrain the client. 4. Administer PRN lorazepam (Ativan) to provide
sedation. - ANS-2
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be
restricted in the client's diet?
1. Protein.
2. Fats.
3. Carbohydrates.
4. Magnesium. - ANS-1
A client has a new prescription for spironilactone (aldactone). Which of the following laboratory
values should the nurse use to notify the provider and withhold the morning dose? ANS-serum
potassium 5.2 If a client has a prescription for valproic (Depakote), which of the following
laboratory values should the nurse expect to monitor? ANS-thrombocytes, amylase count, and
liver function test A client is admitted with a diagnosis of acute appendicitis. When assessing
the abdomen, the nurse would expect to find rebound tenderness at which location?
a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant - ANS-D
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
, 2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture. - ANS-4
A client is given morphine 6 mg IV push for postoperative pain.
Following administration of this drug, the nurse observes the following:
pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the
following nursing actions is MOST appropriate?
1. Allow the client to sleep undisturbed.
2. Administer oxygen via facemask or nasal prongs.
3. Administer naloxone (Narcan).
4. Place epinephrine 1:1,000 at the bedside. - ANS-3
A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour. - ANS-4
A client is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine
that the medication is appropriate if the client displays which of the
the following symptoms? 1. Agitation and decreased level of consciousness.
2. Lethargy and decreased respiratory rate.
3. Restlessness and increased heart rate.
4. Hostility and increased blood pressure. - ANS-3
A client returns to his room following a myelogram. The nursing care
plan should include which of the following?
1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evaluate the client's distal pulses on the affected side. - ANS-1
a client should receive a dose of flumazenil ( romazicon) to treat symptoms of -
ANS-benzodiazepine overdose
a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and
pramipexole ( Mirapex) for which of the following should the nurse monitor this client -
ANS-orthostatic hypotension
a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking
multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid
ibuprofen. why or why not ? - ANS-what , if any is the appropriate action for the nurse to take
NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly
leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should
notify the provider of client headache and ibuprofen us
A client with a peptic ulcer had a partial gastrectomy and vagotomy
(Billroth I). In planning the discharge teaching, the client should be
