NUR 2513 Exam 2 Practice ATI Answer Key
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused
breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
a nurse is caring for a client who has congestive heart failure and is taking digoxin daily the client refused breakfast and is complaining of nausea and weakn
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NUR 2513 Maternal Child Nursing
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Detailed Answer Key
Practice Test #2
1. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused
breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
A. Check the client's vital signs.
Rationale: It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the
nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should
withhold the medication and call the provider if the client's heart rate is less than 60 bpm.
B. Request a dietitian consult.
Rationale: While the dietitian might be able to assist the client with making appropriate food choices, this is
not the first action the nurse should take.
C. Suggest that the client rests before eating the meal.
Rationale: While this intervention might be appropriate, this is not the first action the nurse should take.
D. Request an order for an antiemetic.
Rationale: While this intervention might relieve the client's nausea, this is not the first action the nurse
should take.
2. A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The
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.
3. 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?
Created on:02/09/2021 Page 1
, Detailed Answer Key
Practice Test #2
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.
4. A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse
should inform the client that this medication is contraindicated in clients who have a history of which of the following
conditions?
A. Asthma
Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause
bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle
relaxation.
B. Glaucoma
Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not
contraindicated in a client who has glaucoma.
C. Depression
Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not
contraindicated in clients who have depression.
D. Migraines
Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
5. 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: Temperature is not affected by verapamil.
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, Detailed Answer Key
Practice Test #2
B. Hypotension
Rationale: Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias.
It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A
major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be
monitored before and during parenteral administration.
C. Ototoxicity
Rationale: Verapamil is not toxic to the ear.
D. Muscle pain
Rationale: Verapamil does not cause muscle pain.
6. A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect
of the medication?
A. Decreased blood pressure
Rationale: Lisinopril, an ACE inhibitor, may be used alone or in combination with other antihypertensives in
the management of hypertension and congestive heart failure. A therapeutic effect of the
medication is a decrease in blood pressure.
B. Increase of HDL cholesterol
Rationale: This is not an intended effect of lisinopril.
C. Prevention of bipolar manic episodes
Rationale: This is not an intended effect of lisinopril.
D. Improved sexual function
Rationale: This is not an intended effect of lisinopril. Lisinopril may in fact cause sexual dysfunction and
impotence.
7. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements
by the client indicates an adverse effect of the medication?
A. "I can walk a mile a day."
Rationale: Improving the client's cardiac output, which in turn will improve the client's exercise tolerance, is
a therapeutic response to digoxin.
B. "I've had a backache for several days."
Rationale: Backaches are not an adverse effect of digoxin.
C. "I am urinating more frequently."
Rationale:
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, Detailed Answer Key
Practice Test #2
Improving the client's cardiac output, which in turn will increase blood flow to the kidneys and
urination, is a therapeutic response to digoxin.
D. "I feel nauseated and have no appetite."
Rationale: Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digoxin toxicity.
8. A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency
anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals.
Which of the following responses should the nurse make?
A. "Taking the medication between meals will help you avoid becoming constipated."
Rationale: Taking the medication with food can reduce the GI symptoms associated with it. However,
taking the medication between meals maximizes absorption.
B. "Taking the medication with food increases the risk of esophagitis."
Rationale: Reclining immediately after taking ferrous sulfate may lead to esophageal corrosion. Clients
should remain upright for 15-30 min following administering.
C. "Taking the medication between meals will help you absorb the medication more efficiently."
Rationale: Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron
supplements between meals helps to increase the bioavailability of the iron.
D. "The medication can cause nausea if taken with food."
Rationale: Taking ferrous sulfate with food can reduce the GI symptoms associated with it. However, taking
the medication between meals maximizes absorption.
9. A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the
following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?
A. The leukocyte count
Rationale: Epoetin alfa does not affect the leukocyte, or WBC, count.
B. The platelet count
Rationale: An increase in platelets is not the therapeutic or desired effect of epoetin alfa.
C. The hematocrit (Hct)
Rationale: Epoetin alfa is an antianemic medication that is indicated in the treatment of clients who have
anemia due to reduced production of endogenous erythropoietin, which may occur in clients who
have end-stage renal disease or myelosuppression from chemotherapy. The therapeutic effect
of epoetin alfa is enhanced red blood cell production, which is reflected in an increased RBC,
Hgb, and Hct.
D. The erythrocyte sedimentation rate (ESR)
Rationale:
Created on:02/09/2021 Page 4
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