Which of the following foods should the nurse instruct the client to increase in their diet?
a. Yogurt
b. apples
c. raisins———————– PER NUTRITION BOOK
d. cheddar cheese
23. A nurse is caring for a client who has rights sided pneumothorax. Following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly?
a. Gentle bubbling in the suction chamber——- PG 108 2019 VERSION
b. crepitus around the insertion site
osteoc. constant bubbling in the water seal chamber
d. absence of breath sounds on the right side
24. A nurse is planning care for a client who has acute post streptococcal glomerulonephritis . Which of the following intervention should the nurse include in the client’s plan?
a. Encourage a high-protein diet for the client
b. increase the client’s fluid intake
c. administer diuretics to the client – glomerulnophritis results in fluid retention (because kidneys can’t filter out well) (p. 402-403, 2019)
d. Weigh client twice a week – wrong, should weigh daily
25. A nurse is caring for a client who has a peripheral inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
a. The dressing was changed 7 days ago.
b. The circumference of the client’s upper arm has increased by 10% PG 175
c. The catheter has not been used in 8 hr.
d. The catheter has been flushed with 10 mL of sterile saline after medication use.
26. The nurse is developing a plan of care for a client who will be placed in a Halo surgical repair cervical spine. Which of the following intervention should the nurse include in the plan?
a. Inspect the pin site every 48 hr.
b. Monitor the client’s skin under the halo vest—- pg 474
c. Ensure two personnel hold the halo device when repositioning the client.
d. Apply powder frequently to the client’s skin under the vest to decrease itching.
27. A nurse is caring for a client who has syndrome of inappropriate anti diuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?
a. Urine specific gravity 1.020- pg 284 says “Urine specific gravity: Decreased (1.002 to
1.004 in sodium loss; greater than 1.012 in SIADH)” so 1.020 means not resolving
b. Sodium 119 mEq/L——- wrong bc when have SIADH will have hyponatrmia
c. BUN 8 mg/dL
d. Calcium 8.7 mg/dL – pg 85; I think bc its an electrolyte that is norm range-I PUT
THIS
28. A nurse is caring for a client who is receiving total parenteral nutrition (TPN ). which of the following findings should the nurse identify as a possible complication of TPN administration?
a. Pitting edema of bilateral lower extremities
b. hypoactive bowel sounds in all four quadrants
c. weight is the same as the day before
d. bilateral posterior lung sounds are diminished – I think it is this. TPN can result in fluid
imbalance/hypervolemia (p. 311)
29. A nurse is assessing a client who has a heart rate of 40 /min. the client is diaphoretic and as chest pain period which of the following medication should the nurse plan to administer?
a. Lidocaine– for tachycard
b. Adenosine
c. Atropine————pg 181 chart atropine, dopamine, and epi for bradycard less 60/min
d. Verapamil
30. The nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer’s disease. Which of the following information should the nurse include in the teaching?
a. Explain procedures in full detail to a client before initiating care b. limit a client’s activities to minimize emotional outburst
c. speak clearly and loudly to a client who is unable to form words or sentences
d. provide supervision to prevent a client from becoming injured or lost
31. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?
a. I don’t have muscle spasms as frequently——— PG 46 2016 VERSION
b. I haven’t gotten any colds, even though it is flu season
c. I feel like my nerve pain has improved
d. it is easier to urinate now
32. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). which of the following referral should the nurse plan to initiate?
a. Respiratory therapy
b. Hospice care
c. Occupational therapy
d. Dietary services—– pg 394
14. A nurse is caring for a client who has burn injuries covering their upper body and is concern about their altered appearance. Which of the following statements should the nurse make?
a. It is okay to not want to touch the burned areas of your body
b. cosmetic surgery should be performed within the next year to be effective
c. reconstructive surgery can completely restore your previous appearance
d. injuries
it could be helpful for you to attend a support group for people who have burn
4. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching?
a. I can expect swelling in my hands an on my face—- PER ATI PRE-ASSESS
STUDY GUIDE
b. the amount of protein in my blood is high
c. I might have some pain and gas in my stomach from this condition
d. I will use a soft bristle toothbrush so my gums don’t bleed
10. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following action should the nurse take first?
a. Teach the client to report findings of IV extravasation
b. evaluate the patency of the IV
c. consult with the pharmacist about the prescription
d. verify the prescription with the provider – can’t find in ATI, but google says KCl can cause vomiting/diarrhea, which you wouldn’t want if pt is already dehydrated
13. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?
a. Distended, board-like abdomen
b. WBC count 15,000 /mm3
c. rebound tenderness over McBurney’s point – concur, but can’t find it in ATI on
Children ATI book pg 145 2019 e
d. temperature 37.3 C (99.1 F )—– expected
2. A nurse in an Emergency Department is caring for a client who sustained multiple injuries. The nurse observes client’s thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?
a. Flail chest———— PER PG 157 2019 VERSION
b. Hemothorax
c. Pulmonary contusion
d. Pneumothorax
20. A nurse is assessing a client who has a sodium level of 122 mEq/L. which of the following findings should the nurse expect?
a. Decrease deep-tendon reflexes
b. positive Trousseau’s sign
c. hypoactive bowel sounds
d. sticky mucus membranes
A nurse is providing teaching to a client who is scheduled for electromyography (EMG). the nurse should include which of the following information in the teaching?
a. “You will receive a fixed dose of radioisotope 2 hours before the procedure.”
b. “Momentary flushing will occur at the beginning of the procedure.”
c. “You should inform your provider if you are claustrophobic.”
d. “You should expect insertion of small needle electrodes into the muscles.” pg 448
12. The nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instruction should the nurse include?
a. Eat three large meals daily
b. consume high calorie foods
c. limit caffeinated drinks to two per day
d. drink fluids during meal time
· A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following action should the nurse take first?
a. Maintain IV access.
b. Obtain the client’s vital signs.
c. Contact the provider. d. Stop the transfusion.
· A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instruction should the nurse include in the teaching (select all that apply )
a. Use an electric shaver- pg 615
b. Avoid crowds.
c. Take temperature weekly—– weekly didn’t sound right
d. Consume a low-residue diet- pg 615; not true (low residue is veg and fiber; but in
leukemia- need to restrict)
e. Monitor for bruising——- pg 616
· A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?
o Contact precautions
o Airborne precautions
o Droplet precautions
o Protective environment
· A nurse is caring for a client who is hyperventilating and has the following abgs results PH 7.50, PACO2—29, HCO3—25. The nurse should recognize that the client has which of the following acid base imbalance?
o Respiratory acidosis
o Respiratory alkalosis
o Metabolic acidosis
o Metabolic alkalosis
5. A nurse is planning for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?
a. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
b. administer oxygen to a client who has an oxygen saturation of 91%
c. instructor client who is 1 hour postoperative about coughing and deep breathing exercises
d. initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery
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