NUR 2241 ATI LP4 Exam Questions With Correct Answers

A nurse is caring for an older adult client who has a WBC count of 2000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take? a. Humidify the client's room b. Serve cooked fruit with meals c. Clean dentures in a denture cup d. Replace the water in flower vases with fresh water daily. - Answer b. Serve cooked fruit with meals A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Report the incident to the charge nurse b. Wash the area of the puncture thoroughly with soap and water c. Complete an incident report d. Go to employee health services - Answer b. Wash the area of the puncture thoroughly with soap and water A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? a. Mask b. Gloves c. Gown d. Goggles - Answer b. Gloves A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber - Answer a. Continuous bubbling in the water-seal chamber A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? a. Restlessness b. Retractions c. Dependent edema d. Clubbing of the fingers - Answer d. Clubbing of the fingers A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? a. Blockage of the ET tube by the client's tongue b. Passage of the ET tube into the esophagus c. Movement of the ET tube into the right main bronchus d. Infection of the vocal cords - Answer c. Movement of the ET tube into the right main bronchus A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax - Answer b. Flail chest A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? a. Intracranial pressure b. Spinal cord perfusion c. Renal function d. Hemodynamic status - Answer d. Hemodynamic status A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for ___________. a. Side effects of immunosuppressants b. Constipation c. Fatigue d. Bleeding - Answer d. Bleeding A nurse id planning care for a client who has acute respiratory distress syndrome (ADRS). Which of the following interventions should the nurse include in the plan of care? a. Administer low-flow oxygen continuously via nasal cannula b. Encourage oral intake of at least 3000 mL of fluids per day c. Offer high-protein and high-carbohydrate foods frequently d. Place in a prone position - Answer d. Place in a prone position A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? a. Febrile b. Hemolytic c. Allergic d. Bacterial - Answer b. Hemolytic A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? a. Administer high-flow oxygen at 5 L/min by facemask to the client b. Place the client in high-Fowler's position with legs dependent c. Give the client sublingual nitroglycerin d. Reassure the client - Answer a. Administer high-flow oxygen at 5 L/min by facemask to the client