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NUR 265 Practice ATI Detailed Answer Key | Questions, Answers and Rationales
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NUR 265 Practice ATI Detailed Answer Key | Questions, Answers and Rationales
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Detailed Answer KeyPractice ATI NUR265
1. A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected
cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that
apply.)
A. Hypotension
B. Polyuria
C. Hyperthermia
D. Absence of bowel sounds
E. Weakened gag reflex
Rationale: Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal
cord.Polyuria is incorrect. The nurse should check the client for bladder distention and inability to
urinate due to ineffective function of the bladder muscles.Hyperthermia is incorrect. The nurse
should monitor the client for hypothermia caused by a lack of lack of sympathetic input.Absence
of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the
client to develop a paralytic ileus.Weakened gag reflex is correct. The nurse should monitor the
client for difficulty swallowing, or coughing and drooling noted with oral intake.
2. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the
nurse anticipate?
A. Initiate a low-residue diet.
Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate
the provider will prescribe withholding of foods and fluids. This serves to manage the client's
pain by limiting gastrointestinal activity and stimulation of the pancreas.
B. Pantoprazole 80 mg IV bolus twice daily
Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease
gastric acid production, which ultimately decrease pancreatic secretions.
C. Ambulate twice daily.
Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of
pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes.
D. Pancrelipase 500 units/kg PO three times daily with meals
Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the
treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute
pancreatitis.
3. A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse
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Practice ATI NUR265
identify as an associated risk factor?
A. Hypocalcemia
Rationale: Hypercalcemia is a risk factor associated with urolithiasis.
B. BMI less than 25
Rationale: Obesity, or having a BMI that is greater than 29, has been found to be a risk factor for the
development of urolithiasis.
C. Family history
Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a
client who has kidney stones for familial tendencies toward stone formation.
D. Diuretic use
Rationale: Medications such as antacids, vitamin D, laxatives, and aspirin have been associated with the
formation of urolithiasis. However, there is no indication that the use of diuretics place a client at
an increased risk for stone formation.
4. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following
sets of values should the nurse expect?
A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
Rationale: The nurse should expect a client who has renal failure to have metabolic acidosis, which is
characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges
for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35
to 45 mm Hg.
B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
Rationale: These values indicate respiratory acidosis, which is associated with respiratory disorders, such
as pulmonary edema and pneumonia.
C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
Rationale: These values indicate respiratory alkalosis, which is associated with hyperventilation.
D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Rationale: These values indicate metabolic alkalosis, which is associated with severe emesis or gastric
suctioning.
5. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
(Select all that apply.)
A. Increased heart rate
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Practice ATI NUR265
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature
Rationale: Increased heart rate is correct. The nurse should expect the client who has fluid volume
excess to have tachycardia and increased cardiac contractility in response to the excess fluid.
Increased blood pressure is correct. The nurse should expect the client who has fluid volume
excess to have increased blood pressure and bounding pulse in response to the excess fluid.
Increased respiratory rate is correct. The nurse should expect the client who has fluid volume
excess to have increase in respiratory rate and moist crackles heard in lungs.
Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume
deficit to have an elevated hematocrit because of hemoconcentration.
Increase temperature is incorrect. The nurse should expect the client who has fluid volume
deficit to have an increase in temperature due to fluid loss.
6. A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter
(PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which
of the following actions should the nurse take first?
A. Measure the circumference of both upper arms.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The
nurse should measure the arm and compare the result with the circumference of the other arm.
If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling
could indicate formation of a clot above the site or even catheter rupture.
B. Notify the provider who inserted the PICC line.
Rationale: The nurse should notify the provider to prescribe removing the catheter or initiating other
treatment, such as low-dose thrombolytic therapy; however, there is another action the nurse
should take first.
C. Remove the PICC line.
Rationale: It might become necessary to remove the PICC line, because swelling could indicate clot
formation or catheter rupture; however, there is another action the nurse should take first.
D. Apply a cold pack to the client's upper arm.
Rationale: It might become necessary to apply a cold pack to the client's upper arm to help relieve the
edema; however, there is another action the nurse should take first.
7. A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The
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client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses
should the nurse give?
A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level."
Rationale: The effects of heparin begin within minutes. This response does not accurately answer the
client's question.
B. "A pharmacist is the person to answer that question."
Rationale: Contacting the pharmacist is not the appropriate answer for the nurse to give.
C. "Heparin does not dissolve clots. It stops new clots from forming."
Rationale: This statement accurately answers the client's question.
D. "The oral medication you will take after this IV will dissolve the clot."
Rationale: This is not a correct response. Warfarin, a PO medication that is often started after the client
has been on heparin, does not dissolve clots.
8. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5
days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both
anticoagulants are necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic
level."
Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and
help prevent thrombosis formation in the blood vessels. However, these medications work in
different ways to achieve therapeutic coagulation and must be given together until therapeutic
levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days.
When the client's PT and INR are within therapeutic range, the heparin can be discontinued.
B. "I will call the provider to get a prescription for discontinuing the IV heparin today."
Rationale: Discontinuing the IV heparin is not indicated at this time.
C. "Both heparin and warfarin work together to dissolve the clots."
Rationale: Neither medication dissolves clots that have already formed.
D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."
Rationale: Neither medication increases the effects of the other.
9. A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which
of the following adverse effects should the nurse monitor when giving this medication?
A. Hyperthermia
Rationale:
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