Check before ATI

Question 1

a) S/S inc ICP?
b) what med and how to evaluate effectivness?

Answer 1

a) dilates puplis
brady cardia
restlessness
widened pulse pressure
b) Mannitol
serum osmolarity grater then 300(normal 275 to 295)

Question 2

a) seizure med/phenytoin what to teach?
b) Alzhimer’s modarete and severe s/s?

Answer 2

a) take med at the same time every day
b) forgetness,personality change
-reorient them
severe s/s
need gait belt,thicken all liquid

Question 3

manifestation
a) cataracts
b) angled-closure glaucoma
c) retinal detachment
d) macular degeneration

Answer 3

a) clouding,dec periphela and central vision d/t opacity of the lens, blurried vision
white pupils
b) emergency, sudden severe pain, reduce vision
open-angle gradual loss of vision
c) curtain pulled over the visual field with flashes of light,floating dark spots
d) lose of vision in the center of the visual fiels
Inc intake deep wellow and orange vege

Question 4

after surgery, what should be avoided?
a) cataract
b) detached retina

Answer 4

ding over,lifting, coughing, performing the Valsalva maneuver
limit houskeeping activities

reading or anything can cause rapid movement of the eye

Question 5

a) vanillylmandelic acid test for pheochromocytoma, what to teach?
b) HHS glucose level?
c) HbA1c what level indicates DM?

Answer 5

a) avoid caffeine intake 2-3 days before
24-hr urine specimen to test for VMA. This test is used to determine if the client has pheochromocytoma,
b) greater than 600, normal pH
c) greater than 6

Question 6

a) diabetes insipidus, what lab change require to notify?
HR?hematocrit? urine specific gravity?BUN?
b) postprandial blood glucose range?
c) random blood glucose range?
d) preprandial blood glucose?

Answer 6

a) nocturia cause need to inc dosage until they no longer has nocturia
Tachycardia
Inc hematocrit
low gravity
Inc BUN
B) 180(after a meal.)
c) less than 200
d) 70-130

Question 7

a) propylthiouracil used for?
b) Administer nasal spray, what to teach?
c) Cushing’s disease, K and Ca level?

Answer 7

a) production of thyroid hormones and allows weight gain
b) blow nose before
c) hypo

Question 8

a) pt who has acromegaly, s/s?
b) SIDAH, Na level?
c) Somogyi effect and takes intermittent insulin, what to plan?
d) thyroidectomy to treat hyperthyroidism, what abnormal findings need to report?

Answer 8

a) inc head size
b) hypo
c) take nighttime blood glucose
dec bedtime insulin
Inc bedtime snack
d) tachycardia, HTN
laryngeal and hoarseness
positive trousseau’s sign

Question 9

a) UTI common s/s?
b) CKD recommend diet?
c) risk factors(disease) of chronic pyelonephriris?

Answer 9

a) Pyuria(WBC in urine)
urgency and dysuria
back pain
b) dec intake of high phosphorus
low protein,and high iron
c) DM
also avoid the use of NSAIDs

Question 10

a) pt is scheduled for an intravenous urography. what priority?
b) what factor places the pt at risk for seizures following hemodialysis
c) after renal biops, what to teach?

Answer 10

a) determine if the pt has an allergy to iodine or shellfish
b) a rapid dec in fluid
c) bed rest supine for 2-24hr

Question 11

a) s/s of bladder trauma?
b) ADR of peritoneal dialysis?
c) pt has a diagnosis of renal calculi and reports severe flank pain. what it the first care?

Answer 11

a) hematuria
b) peritonitis
c) releve pain

Question 12

a) CKD, what limit?
b) transurethral resection of the prostate, what findings to report?
c) peritoneal dialysis.Bag is where to place?

Answer 12

a) limit fluid intake
b) dec urine output
After a TURP, the client will feel the urge to urinate.
a surgery to remove the inside part of the prostate gland
client will require an indwelling urinary catheter following a TURP to monitor urine output and bleeding.
c) below the pt’s abdomen

Question 13

a) pre-ope teaching for a cystoscopy?
b) albuterol ADR?
c) continuous bubbling in the water seal chamber?

Answer 13

a) expect have pink-tinged urine after ope
a procedure to look inside the bladder using a thin camera
b) tachycardia
c) air leak

Question 14

a) keep drainage where?
b) suction control chamber
c) water seal chamber
d) possible indication of lung re-expansion?
c) collection chamber, what to notify?

Answer 14

a) below the chest
b) gentle, steady or continuous bubbling
c) one-way valve, NO continuous bubbling
tideline(rise and fall) is GOOD
d) tidaling in the water chamber stopped
e) bright red 100ml/hr(dark red is OK)

Question 15

a) emphysema, what findings to report?
b) TB med rifampin, what to teach?
c) cisplatin for lung cancer, ADR?

Answer 15

a) elevated temp
b) urine and other secretion to be orange
c) Tinnitus(ototoxicity)

Question 16

a) sublingual nitroglycerin what to teach?
b) fluid volume deficit abnormal virtal?
c) Pneumonia s/s?

Answer 16

a) lie down to take
b) HR 110
c) cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain.

Question 17

a) enalapril ADR?
b) what is a productive cough?
c) potential problem?

Answer 17

a) orthostatic hupotension
b) AKA wet cough, is one that brings up mucus
c) what could go wrong

Question 18

0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused.
Blood pressure 88/50 mm Hg
Heart rate 110/min
Respiratory rate 24/min
Oxygen saturation 93% on room air

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated (I or NI)

1) Obtain the client’s blood glucose level
2) Apply oxygen at 2 L/min via nasal cannula
3) Notify the provider immediately.
4) Place the client in Trendelenburg postion
5) Administer a 0.9% sodium chloride 200 mL IV bolus
6) Perform a 12 lead ECG

Answer 18

1) Obtain the client’s blood glucose level (NI)

2) Apply oxygen at 2 L/min via nasal cannula (I)

3) Notify the provider immediately. (I)

4) Place the client in Trendelenburg position. (I)

5) Administer a 0.9% sodium chloride 200 mL IV bolus (I)

6) Perform a 12 lead ECG (NI)

Question 19

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?

Place the client in supine position

Measure vital signs

Cover the wound with a sterile, saline-moistened dressing

Call for help

Answer 19

Call for help

-Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock. Therefore, the nurse should obtain immediate assistance

Question 20

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 the following actions?

Neutralizing gastric acid

Reducing the growth of ulcer-causing bacteria

Coating the stomach lining

Suppressing gastric acid production

Answer 20

Suppressing gastric acid production

-Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid pro

Question 21

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 provider.

Restlessness

T3 level 215 ng/dL

Blood pressure 170/80 mm Hg

Decreased weight

Answer 21

Blood pressure 170/80 mm Hg

-systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

Rationale

Nonurgent expected finding

-Restlessness

-Elevated T3 level

-decrease weight

Question 22

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?
-Shellfish
-Peanuts
-Eggs
-Avocados

Answer 22

Avocados

-avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
-egg and peanut allergy might have an allergic reaction to propofol.

-shellfish allergy might have an allergic reaction to povidone-iodine.

Question 23

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates and understanding of the teaching?
-“I will take my iron with a glass of milk.”
-“I will take an antacid with my iron.”
-“I will limit my intake of red meat.”
-“I will eat more high-fiber foods.”

Answer 23

“I will eat more high-fiber foods.”
-eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

Question 24

nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
Low urine specific gravity
Hypertension
Bounding peripheral pulses
Hyperglycemia
sponsiveness to the hormone.

Answer 24

Low urine specific gravity

-diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys’ re

Question 25

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of the condition?
Bounding pedal pulse
Capillary refill less than 2 seconds
Pain that increases with passive movement
Areas of warmth on the cast

Answer 25

Pain that increases with passive movement

-a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

Question 26

a) traumatic brain injury, what is cushing’s triad?
b) HIV,low Viral load means?

Answer 26

a) Bradycardia
Hypertension
widened pulse pressure
b) little HIV in your blood that the test can’t find it
means positive response to the prescribed HIV treatment

Question 27

A nurse is teaching a client about the use of TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects?

Electrically generated feelings of heat
Cryotherapy for painful areas
Realignment of energy flow through meridians
A tingling sensation replacing the pain

Answer 27

A tingling sensation replacing the pain

-applies small electric currents to the painful area, with the client increasing the current until the “pins and needles” sensation overrides the pain

Rationale

• over-the-counter gels and creams work by creating a sense of cold to help relieve muscles aches and pain. A TENS unit does not work by cryotherapy, or heat

-cupuncture is a therapy that works via the insertion of fine needles to help unblock any obstructed flow of energy in other parts of the body

Question 28

A PACU nurse is assessing a client who is postop following a right nephrectomy. The client’s initial vital signs were heart rate 80/min, BP 130/70, RR 16/min, and temp 96.8. which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min
Blood pressure 160/70 mm Hg
Respiratory rate 14/min
Temperature 38.4° C (101.1° F)

Answer 28

Heart rate 110/min

-first signs of hemorrhage is an increase in the heart rate from the client’s baseline, which occurs to compensate for blood loss.

Question 29

A nurse is assessing a client while suctioning the client’s tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client starts to cough.
The client’s heart rate increases.
The client is diaphoretic.
The client’s blood pressure decreases.

Answer 29

The client’s heart rate increases.

-Hypoxia related to suctioning can cause the client’s heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.

Question 30

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?

The client’s urinary output has increased.
The client reports back pain.
The client’s urine color is red tinged.
The client’s tube requires irrigation.

Answer 30

The client reports back pain.

-notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

Rationale

-Red-tinged urine is an expected finding for the first 12 to 24 hr

-client tube needing irrigation is expected

Question 31

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse’s priority to report to the provider?

Temperature 37.2° C (99° F)
Blood pressure 100/70 mm Hg
Weight loss
Restlessness

Answer 31

Restlessness

-nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client’s blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.

Question 32

A nurse is planning care for a client who is postop following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Set the wall suction to 80 to 100 mm Hg.

Compress the drain reservoir after emptying.

Allow the drainage to collect on a sterile gauze dressing.

Position the drain below the bed to promote drainage.

Answer 32

Compress the drain reservoir after emptying.

-Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

Question 33

A nurse is providing postop teaching for a client who had a total knee arthroplasty. Which if the following instruction should the nurse include?

Flex the foot every hour when awake.

Place a pillow under the knee when lying in bed.

Lower the leg when sitting in a chair.

Ensure the leg is abducted when resting in bed.
Flex the foot every hour when awake.

Answer 33

-flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

Rationale

-avoid placing pillows under the knee to prevent flexion contractures.

-keep the operative leg in a neutral position when resting in bed to prevent dislocation of the knee.

Question 34

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

Serosanguineous drainage on the dressing

Capillary refill of 2 seconds

Client report of discomfort when moving toes

Answer 34

Extremity cool upon palpation

-report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client’s extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

Question 35

When to perform ECG?
When to perfrom trendelenburg position?

Answer 35

Perform a 12-lead ECG is not indicated. The client is not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time.
The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion.

Question 36

how to use cruthes

Answer 36

place their body weight on the crutches.
advance the unaffected leg onto the stair. shift their weight from the crutches to the unaffected leg.
bring the crutches and the affected leg up to the stair.

Question 37

a) meningitis s/s
b) migraine s/s?
c) mifraine med?

Answer 37

a) Hand grasps,Visual changes
b) neurological manifestation with flashing lights and resolve after 1hr
stroke won’t resolve in an hour
c) sumatriptan
- can cause coronary vasospasms.
- used to treat an occurring migraine only PRN for pain

Question 38

Answer 38

Oxygenation and blood pressure are correct. Using the airway, breathing, circulation priority framework, the nurse should first address the client’s oxygenation, followed by the client’s blood pressure. The client’s oxygenation is below the expected reference range and is the priority. The nurse should then address the client’s circulation because the client’s blood pressure is below the expected reference range.

Question 39

When hypovolemia

Answer 39

when hypovolimea, do not trendelenburg!!!!Place the client in Trendelenburg position is contraindicated. Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their head of bed no more than 30° to promote venous return to the heart.

Question 40

Chest tube

Answer 40

Question 41

improvment

Answer 41

Wound dressing is dry and intact is correct. The nurse should identify that a dry and intact wound dressing indicates the client’s wound is no longer bleeding.