Update 2025 100% Correct
nurse is assessing a client who is 12hr postoperative following a colon resection. Which of thefollowing
findings should the nurse report to the surgeon?
Heart rate 90/min
Absent bowel sounds → normal findings after major bowel surgery; takes several days to returnto
normal.
Hgb 8.2 g/dl
Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.
A nurse is caring for a client who has diabetes insipidus. Which of the following medications shouldthe
nurse plan to administer?
a. Desmopressin
Regular insulin
b. Furosemide
Lithium carbonate
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH
and keepspt. on urinating
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for3
years. Which of the following test should the nurse monitor?
Fasting blood glucose
Stool for occult blood
Urine for white blood cells
Serum calcium
Rationale:ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abd pain).
A nurse in the emergency department is assessing a client. Which of the following actions should the
nursetake first (Click on the “Exhibit” button for additional information about the client. There are three
tabs that contain separate categories of data.)
Obtain a sputum sample for culture
Prepare the client for a chest x-ray
Initiate airborne precautions
Administer ondansertron.
Rationale: No idea what the Exhibit is all about; wont be able to answer it.
A nurse is contacting the provider for a client who has cancer and is experiencing breakthroughpain.
Which of the following prescriptions should the nurse anticipate?
Transmucosal fentanyl
Intramuscular meperidine
Oral acetaminophen
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,Intravenous dexamethasoneRationale:ATI pg. 27
A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which
ofthe following should the nurse analyze to determine whether the client is experiencing a myocardial
infarction?
PR interval
QRS duration
T wave
ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which
of the following instructions should the nurse include?
Pat the skin on the radiation site to dry it
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, Apply OTC moisturizer to the radiation site
Cover the radiation site loosely with a gauze wrap before dressing
Use a soft washcloth to clean the area around the radiationsite Rationale: pg. 584. Dry the area
thoroughly using patting motions.
A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has
bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate
administering which of the following prescribed medications?
c. Diphenhydramine
d. Acetaminophen
e. Pantoprazole
f. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to
preventcardiovascular/respiratory distress.
A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
Lungs clear
Apical pulse 82/min
Hyperactive bowel sounds
Blood pressure 90/50 mm Hg
Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation,
paralytic ileus. Soeffectiveness would indicate opposite of this
A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse
should recognize these findings as indication of which of the following conditions?
Metabolic acidosis
Metabolic alkalosis
Compensated respiratory alkalosis
Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis
A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which ofthe
following labs should the nurse expect during the first 24 hours
Decreased BUN ELEVATED DT fluid loss
Hypoglycemia (High due to stress)
Hypoalbuminemia (Low due to fluid loss)
Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)
(Page 481 ch 75 med surge ati pdf 10.0)
A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following
actions should the nurse take ?
Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderatecarbs
page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0)
Provide the client with four full meals a day (Small frequent meals)
Encourage the client to to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1hr
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