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Exam (elaborations) NURSING MISC MAIN VERSION PRIORITY ONE
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Exam (elaborations) NURSING MISC MAIN VERSION PRIORITY ONE Exit Exam
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MAIN VERSION PRIORITY ONE1. Missing
2. A nursing planning care for a school-age child who is 4 hr postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the plan
of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short-term
(24 to 48 hr) around-the-clock administration of opioids is preferable to following a PRN
schedule.
ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO
cromolyn nebulizer stated on ATI.
3. A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR,
decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress,
tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur
after injury usually within 12-48 hrs
4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse tak e?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to
promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply
immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together)
Rationale https://medlineplus.gov/druginfo/meds/a601084.html : How to apply patch
Rationale ATI Skills Module Medication Administration: Topical medications include
lotions, creams, ointments, patches, and paste. Because topical medications are absorbed
by the skin, wear gloves when applying them to protect yourself against accidental
exposure
Shaving may cause skin irritation and change the absorption of the drug.
5. A nurse has just received change-of-shift report for four clients. Which of the
following clients should the nurse assess first?
a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hr (can wait)
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
d. A client who received a pain medication 30 min ago for postoperative pain
Rationale Med Surg ATI PDF p529: assess for improvement or worsening of
hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and
recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens.
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
,Rationale ATI MS p309: Complications: Aspiration of gastric secretion Causes: Reflux of
gastric fluids into the esophagus can be aspirated into the trachea.
7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease.
The nurse should expect the client to have an INCREASED in which of the following
laboratory values?
a. Serum glucose level- increased
b. Serum calcium level-decreased
c. Lymphocyte count- decreased immune system.
d. Serum potassium level- decreased
Rationale ATI MS PDF p518: Cushing disease→ everything is UP except Potassium &
Calcium: DECREASED.
8. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after
the client displaces toxicity. Which of the following actions should the nurse take? P .
235 pharm ch 30
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate
toxicity. Always have an injectable form of calcium gluconate available when administering
magnesium sulfate by IV.
9. A charge nurse is teaching new staff members about factors that increase a client’s
risk to become violent. Which of the following risk factors should the nurse include as the
best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison
Rationale ATI MH p185: Risk factors also include: past history of aggression, poor
impulse control, and violence. Comorbidity that leads to acts of violence (psychotic
delusions, command hallucinations, violent angry reactions with cognitive disorders).
Rationale ATI COMMUNITY p50: Individual Assessment for Violence
10. A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the
body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5
cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;
should be ABOVE waist level
Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap from
bottle in upward motion.
11. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who lives
alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
,b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments
Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from?”
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g.
birthdate). OR ask the client to state a fact from their past that is verifiable.
Memory of events that occurred in the distant past.
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching? P .528 med surg
ch 82
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON
COMPLIANT
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC
d. HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management of grand mal
seizures and has a new prescription for isoniazid and rifampin. Which of the following
should the nurse conclude if the client develops ataxia and incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under control
c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions
Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive
impairment (http://emedicine.medscape.com/article/816447-clinical#b4 also states that
this is an indication of phenytoin toxicity); According to my Davis Drug Guide book,
progressive s/s of phenytoin toxicity include ataxia, nystagmus, confusion, nausea, slurred
speech & dizziness.
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of
the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)
Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki
disease. Which of the following interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hr
b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
Rationale ATI PDF p: PEDS p. 120 Monitor VS, cardiac status. Maintain cardiac monitoring.
Assess for HF ( decrease urine output, gallop heart rhythm, tachycardia, respiratory
distress)
Kawasaki disease cause inflammation in the walls of medium-sized arteries throughout the
body. It primarily affects children. The inflammation tends to affect the coronary arteries,
which supply blood to the heart muscle.
, 18. A nurse is planning an educational program for high school students about cigarette
smoking. Which of the following potential consequences of smoking is most likely to
discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in life
c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
Rationale ATI PDF p:33 PEDS Age appropriate activities for highschool students: sports,
video games, music, social events.
19. A nurse is assessing a client who is prescribed spironolactone. Which of the following
laboratory values should the nurse monitor for this client? P . 146 ch 19 CONFIRMED
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned
to another nurse. Which of the following statements by the nurse indicates an
understanding of this role?
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.”
c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.”
Rationale ATI PDF p: Makes most sense (best rationale yet)
21. A nurse is performing assessments on newborns in the nursery. Which of the following
findings should the nurse report to the provider? P . 156 ch 23 MATERNITY PDF
a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
they can be is RESPIRATORY DISTRESS
b. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass
stool
c. A 2 day old newborn who has a small amount of blood tinged vaginal discharge
d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the
following clients should the nurse assess first? Pain pallor pulselessness paresthesia
a. A client who is 1 hr postoperative and has hypoactive bowel sounds
b. A client who has fractured left tibia and pallor in the affected extremity
c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
d. A client who has a elevated AST level following administration of azithromycin
Rationale: circulation is affected; ABCs
23. A nurse is providing discharge instructions to a client who has a new prescription for
haloperidol which of the following adverse effects should the nurse instruct the client to
report to the provider?
a. Weight gain
b. Dry mouth→ anticholinergic effects
c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening
d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported
to the provider. ATI PHARM 110
Rationale: e book pg 69 ch 10
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