A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate?
A.) Apply cold compresses to the affected extremity
B.) Apply warm compresses to the affected extremity
C.) Keep the affected extremity above the level of the...
ATI Comprehensive Exit Exam 7 2024
A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity.
Which intervention is appropriate?
A.) Apply cold compresses to the affected extremity
B.) Apply warm compresses to the affected extremity
C.) Keep the affected extremity above the level of the heart
D.) Keep the affected extremity below the level of the heart - ANSWER--->D.) Keep the
affected extremity below the level of the heart
RATIONALE: The nurse should NEVER apply direct heat to the limb. Sensitivity is decreased
in the affected limb & burns may result
A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing
interventions has the highest priority?
A.) Securing the tube and drainage bulb to the pt
B.) Keeping the drainage bulb depressed to manual suction
C.) "Milking" the tubing before emptying the drain
D.) Cleansing the insertion site of the tube w/betadine - ANSWER-->B.) Keeping the drainage
bulb depressed to manual suction
RATIONALE: Securing the tubing helps to keep tension from being placed on the tubing &
bulb. While this is helpful, maintaining the bulb to suction is the highest priority nursing
intervention
A client is scheduled for surgery. Which of the following findings should the nurse report to the
provider prior to surgery?
A.) Serum potassium of 3.8 mEq/L
B.) A missing identification band
C.) Increased anxiety level
D.) A decrease in BP - ANSWER-->D.) A decrease in BP
RATIONALE: If a missing ID band is noted the nurse can recreate the band prior to proceeding
to the operating room. The ID band is a method of properly identifying a pt & necessary for care
A client is undergoing cystoscopy. Which of the following interventions should the nurse include
in the client's plan of care?
A.) Provide education on home urinary catheter care
B.) Monitor for infection for 48-72 hours following procedure
C.) Increase oral fluid intake to flush contrast dye from system
D) Educate pt on the need for anticoagulant therapy - ANSWER--->B) Monitor for infection for
48-72 hours following procedure
,RATIONALE: Cystoscopy does not require administration of contrast dye
A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and
now has in place a chest tube for drainage. What finding would require the nurse to contact the
provider immediately?
A.) Chest tube & tubing become disconnected during pt transfer
B) Pt complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry
C) Chest tube drainage measures 80 mLs/hr of red blood
D) Diminished breath sounds auscultated in left lower lobe - ANSWER-->C) Chest tube
drainage measures 80mL/hr of red blood
RATIONALE: If the tubing separates the RN will ask the pt to exhale as much air as they can to
remove air from the pleural space & the nurse would cleanse the tips & reconnect the tubing
A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis.
Which of the following should be included?
A.) Increase intake of dietary calcium
b. Walking for one to two hours daily is recommended.
c. Eliminate safety hazards in the home
d. Long-term estrogen replacement therapy will be required. - ANSWER-->C.) Eliminate safety
hazards in the home
RATIONALE: Intake of calcium alone is not a treatment for osteoporosis, but calcium is an
important part of a prevention program to promote bone health. Most people do not get enough
calcium in their diet, and therefore calcium supplements are needed.
A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least
reliable method to determine correct NG tube placement?
a. Aspirate to collect gastric content.
b. Test pH of gastric contents
c. Ask the client to talk.
d. Inject air into tube and listen over abdomen. - ANSWER-->D.) Inject air into tube and listen
over abdomen
RATIONALE: Other than X-ray, aspiration of gastric contents with pH testing is the most
reliable method to determine correct NG tube placement. A pH of 4 or less is expected.
A nurse is caring for a client with heart failure. Which of the following interventions should the
nurse take if the client is experiencing dyspnea?
a. Place client in high Fowler's position.
b. Place client in the reverse trendelenberg position
,c. Perform coughing and deep breathing exercises every 8 hours.
d. Obtain serial ABGs every 8 hours. - ANSWER-->A) Place pt in high fowler's position
RATIONALE: Placing the client in reverse trendelenberg would not promote lung expansion and
improve oxygenation as well as high Fowler's position.
A nurse is providing education to a client with coronary artery disease. Which of the following
cholesterol values should the nurse identify as a goal for this client?
a. HDL-C level 60 mg/dL
b. HDL-C level 20 mg/dL
c. LDL-C level 98 mg/dL
d. LDL-C level 120 mg/dL - ANSWER-->A) HDL-C level 60 mg/dL
RATIONALE: While a value of <130 mg/dL is an accepted normal value, this client has
coronary artery disease and a value below 70 mg/dL is desirable for clients diagnosed with CVD
or who are diabetic.
A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical
manifestation requires immediate attention by the nurse?
a. Increase in pulse rate
b. A decrease in temperature
c. A decrease in blood pressure
d. Increased oxygen saturation - ANSWER-->C) A decrease in BP
RATIONALE:An increase in a client's pulse rate is a finding that needs additional data
collection because it may be indicative of an autonomic response to pain, anxiety, and other
A nurse is caring for a client with a new onset bowel obstruction. What assessment finding
would be anticipated when completing an abdominal assessment?
a. Hyperactive bowel sounds.
b. Hypoactive bowel sounds.
c. Normal bowel sounds.
d. Absent bowel sounds. - ANSWER-->A) Hyperactive bowel sounds
RATIONALE: Hypoactive bowel sounds may be found in later stages of obstruction, but
hyperactive bowel sounds are typical in early stages of obstruction.
A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following
findings should be reported to the provider immediately?
a. Hyperactive deep tendon reflexes
b. Increase in white blood cell count from 6,000 mm3 to 8,000 mm3
c. Increase in temperature from 99.5 F to 100.5 F
, d. Increased number of stools - ANSWER-->C) increase in temp from 99.5 to 100.5 F
RATIONALE: Hyperactive deep tendon reflexes are a common manifestation of Grave's disease.
A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse
monitor for manifestations of atelectasis?
a. Intake and output
b. Pulse oximetry
c. Lung sounds
d. Daily weight - ANSWER-->B) pulse oximetry
RATIONALE: Lung sounds should be monitored in the client at risk for atelectasis but this is not
the best method to monitor for the manifestations of atelectasis.
A nurse is caring for a client post aortofemoral bypass surgery. Which of the following
interventions would be contraindicated?
a. Monitoring client for changes in blood pressure.
b. Encouraging client to sit in high Fowler's position.
c. Maintaining NPO status until first postoperative day.
d. Coughing and deep breathing every 1 to 2 hours. - ANSWER-->B) Encouraging pt to sit in
high-fowlers position
RATIONALE: Coughing and deep breathing should be encouraged to promote gas exchange and
prevent atelectasis.
A client is discharged following a cardiac catheterization procedure. Which of the following
should the nurse include in the discharge teaching?
a. Tub baths the night following the procedure are acceptable.
b. Notify provider if bruising is noted at the site.
c. Remove dressing the evening of the procedure.
d. Limit activity for several days after the procedure. - ANSWER-->D) limit activity for several
days after the procedure
RATIONALE: Mild bruising at the insertion site is not unusual and will resolve after several
days.
A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes
the need to stop the test if which of the following occurs?
a. The client begins to breathe harder
b. The client experiences an increase in heart rate.
c. An ST segment depression or T wave inversion on the EKG.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller TippingPerotta. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.08. You're not tied to anything after your purchase.
