ATI NCLEX Medical Surgical Assessment 1 with correct answers100%[verified and updated]/24/, Exams of Nursing

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ATI NCLEX Medical Surgical Assessment 1 with correct

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1. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr: A Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc -- B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia. Turn the client q 2hr to prevent complications related to immobility C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia 2. A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effective- ness of the treatment A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1. D. Hct 62%: C Within the expected range of 1.005-1. -- A, sodium range is 136-145 B, potassium range is 3.5-5 D, Hct

range is 37%-52%

3. A nurse is monitoring the laboratory findings for a client who is postoper- ative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding A. PT 11.5 seconds B. aPTT 35 seconds C. Platelets 80, D. RBC 4.0 million: C platelet range is 150,000-400, -- A, PT range is 11-12. B, aPTT range is 30-40 seconds D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not indicate that the client is at risk for bleeding 4. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse's priority while caring for this client A. Change the client's position every 2 hours B. Pad pressure points at the edges of the client's cervical collar C. Palpate the client's abdomen for bladder distention D. Assist the client with quad coughing: D The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing) 5. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-as- sociated circulatory overload A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia: C Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes

wheezing, chest tightness, cyanosis, and low BP

A, nausea can indicate an acute hemolytic transfusion reaction B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphy- lactic D, bradycardia is not an indication

6. A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy A. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold: C Altered taste is a result of the release of metabolites by dead cells -- A, client may have hair loss at the treatment site on the chest B, client might have skin changes, such as dryness and increased sensitivity D, avoid heat exposure 7. A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take (select all that apply) A. Obtain pre-transfusion temperature B. Prime the IV tubing with lactated Ringer's C. Instruct an assistive personnel to monitor the client during the transfusion D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access: A, D, E -- A, complete assessment prior to transfusion B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or

5% dextrose! C, nurse should remain with pt for first 15 minutes of transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow

8. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18.7 mg/dL D. 26 mg/dL: D Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues -- A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid over- load, or nephrotic syndrome 9. A nurse is reviewing ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation (cannot insert pictures, read description) A. multiple irregular and variable waves at the baseline and irregular R to R intervals B. a rate of 140-180/min C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min D. a P wave for every QRS, rate is 60-100/min: A --

B, Vtach C, SVT D, normal sinus

10. A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client's room upon admission A. Obturator B. Hydrogen peroxide C. Sterile gloves D. Inner cannula: A The obturator can be inserted in the stoma in the even of dislodgment or decannu- lation to maintain an airway until a new trach tube can be placed. For the first 72 hr following the insertion of a trach, dislodgement or decannulation is considered an emergency -- B, used for trach care, but not priority C, sterile gloves for suctioning or for dressing change, but not priority D, inner cannula in case it needs to be replaced, but not priority 11. A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2 days ago. Which of the following statements should the nurse use to assess how the client is coping with this change in their body image A. "Tell me how the changes to your leg make you feel" B. "What potential changes do you think you'll need to make when doing your job" C. "Let's discuss how you can adjust once you have a prosthesis" D. "What are some possible issues that you foresee when completing self- management tasks": A 12. A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include A. "Wait at least 5 minutes between puffs from the same inhaler" B. "Breathe in rapidly when inhaling the medication"

C. "Clean the plastic inhaler cap weekly with cold water" D. "Shake the inhaler vigorously prior to use": D Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily -- A, wait at least 30 to 60 seconds between puffs of the medication. Wait 2-5 min between using different medications from separate inhalers B, breathe in slowly and deeply to distribute the medication evenly throughout the bronchiole tissue. If the spacer makes a whistling noise, they are breathing too rapidly C, clean the spacer weekly and the plastic cap of the inhaler at least once daily by rising them in warm water

13. A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy for colon cancer screening. Which of the following information should the nurse provide A. "You should have nothing to eat or drink for 3 hours prior to the procedure" B. "You should drink the bowel preparation slowly to prevent nausea" C. "You will have no discomfort following the procedure" D. "You will need someone to drive you home after your procedure": D Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt receives moderate sedation -- A, begin a clear diet the day before the procedure. The pt should have nothing to eat or drink for 4- hr prior to the procedure B, drink the bowel prep quickly to minimize nausea C, it is typical to have cramping and a feeling of fullness after a colonoscopy d/t the instillation of air into the bowel during the procedure 14. A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse A. Oxygen saturation 90%

B. No response to verbal stimuli C. Occasional premature ventricular contractions (PVCs) D. Nausea: B using urgent vs non-urgent approach, this is the priority. During moderate sedation, the pt should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss or consciousness or oversedation

15. A nurse is reviewing the laboratory findings for a client who has heart fail- ure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication A. Sodium 142 mEq/L B. Metabolic acidosis C. Potassium 3.2 mEq/L D. Hypoglycemia: C Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias -- A, monitor for hyponatremia (sodium < 136) B, furosemide can cause metabolic alkalosis, monitor for cramping, twicthing, and increased HR D, furosemide can cause hyperglycemia 16. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (select all that apply) A. Monitor peripheral pulses in the affected extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every 24 hrs D. Examine the skin under the traction bood E. Assess the temperature of the affected extremity: A, D, E -- A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device B, weights should hang freely away from the foot of the bed to promote proper traction and healing. Hanging freely provides counter traction that diminishes muscle

spasms C, Buck's is a short term treatment with weights ranging 2.3-4.5 kg (5-10lb). Nurse does not adjust the weight without a prescription from the provider D, monitor skin integrity at least every 8 hr E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P's: pain, pallor, pulse- lessness, pressure, paresthesia, and paralysis

17. A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching A. Lock doors leading to stairways B. Instruct the client not to use the stove C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep: A This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease -- B, learning and memory are loss impaired, so it is unrealistic to expect this pt to remember instructions long term. Caregiver should remove the knobs or controls on the stove so the pt cant turn it on C, at a high risk for falls, rugs increase risk for slipping D, loss of cognition and recognition of environment. Keeping the room dark will further decrease the ability of the client to gain their bearings and places the client at risk for falls. Use a night-light 18. A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet B. Perform a vascular assessment for the client every 6 hr C. Maintain the head of the client's bed at 15 degrees at all times D. Place the client on contact precautions: A

Meningitis often causes photophobia and phonophobia. Reduce stimuli

B, risk of thrombotic or embolic complications, perform a vascular assessment at least every 4 hours or more often as needed C, head of bed should be elevated to 30 degrees at all times. Remain on bedrest until activity is tolerated D, meningitis needs droplet precautions for the first 24 hr of antibiotic therapy to prevent transmission. If viral meningitis is confirmed diagnosis, the precautions may be removed

19. A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take A. Ask the client to exhale slowly B. Turn the client's head to the right C. Place the client in a semi fowlers position D. use aseptic technique: D aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set -- A, ask pt to perform the valsalva maneuver by inhaling, holding their breath, and bearing down to prevent any air from entering the catheter when disconnecting and reconnecting the new set B, turn clients head to the left to facilitate access to the clients catheter, which is located in the right subclavian vein C, the client should lie flat to ensure the catheter exit site is at or below the level of the heart when disconnecting and reconnecting the new set 20. A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client A. Recombinant herpes zoster

B. Human papillomavirus C. Live attenuated influenza D. Varicella: A herpes zoster= shingles Older adults can get either the live or recombinant herpes zoster immunization -- B, the HPV vaccine is recommended only for pt < 26 years old C, live attenuated influenza vaccine is recommended only for pt <49 years old. Older adults should receive inactivated or recombinant influenza immunization D, varicella is recommended only for pt born after 1980

21. A nurse is caring fro a client who has continuous bladder irrigation fol- lowing a transurthral resection of the prostate (TURP). Which of he following actions should the nurse take A. Place the indwelling urinary catheter tubing so it lies freely between the client's legs B. Irrigate the indwelling urinary catheter using sterile water C. Subtract the amount of irrigation solution from the indwelling urinary catheter output D. Flush the indwelling urinary catheter with 30mL of irrigation solution to clear an obstruction: C Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag -- A, fasten the drainage tube securely to the client's thigh B, use sterile 0.9% sodium chloride irrigation, which is an isotonic solution, for bladder irrigation. Sterile water is hypotonic and can be absorbed if used as an irrigation solution, causing fluid shifts and dilutional hyponatremia D, irrigate with 50 mL of irrigation solution to free an obstruction in the catheter 22. A nurse is administering epinephrine IV to a client who is having an ana- phylactic reaction. Which of the following findings should the nurse identify as a therapeutic response to the medication

A. Hypoglycemia B. Thickened bronchial secretions C. Regular heart rate with hypotension D. Non itchy skin wheals: D A pt in anaphylactic shock can experience intensely itchy skin with wheals or hives that can merge to form large red blotches. Epi blocks the release of histamine and decreases erythema, angioedema, and hives. This finding indicates a therapeutic response to the epi -- A, hyperglycemia is an adverse effect of epi. Hypoglycemia from the administration of epi does not indicate a therapeutic response to the medication B, a client in anaphylactic shock can have an increase in congestion, tongue and larynx swelling, and increased mucus production. Decreased bronchial secretions and a clear airway indicate and therapeutic response to epi C, a client in anaphylactic shock can have hypotension and a rapid, weak, irreg- ular pulse from vasodilation of vessels and extensive capillary leaks. Absence of hypotension and an elevated HR indicate an therapeutic response to epi

23. A nurse is assisting in selecting foods for lunch with a client who has diverticulosis. Which of the following foods should the nurse recommend as the best source of fiber A. 1 slice of rye bread B. 1/2 cup cooked navy beans C. 1/2 cup cooked asparagus D. 1/2 cup watermelon: B navy beans contain 5g of fiber per 1/2 cup -- A, 1 slice of rye bread has 1g of fiber C, 1/ cup of asparagus has 1g fiber D, 1/2 cup of watermelon has 0.3 g fiber 24. A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of

the teaching A. "I will wear my graduated compression stockings while sleeping" B. "I will elevate my legs for 10 minutes 3 times per day" C. "I will limit the time I spend sitting down during the day" D. "I will cross my legs at my knees when sitting": C Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis -- A, wear graduated compression stockings during the day and evening, remove stockings at bedtime B, elevate legs for at least 20 minutes 4 or 5 times per day. When lying down, elevate the legs above the level of their heart D, do not cross legs when sitting

25. A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommen- dations should the nurse include in the teaching? A. "Try to avoid sun exposure by waiting until after sunset to go outdoors" B. "Gently was the irradiated area to remove the markings before going outside" C. "Protect exposed skin with an over the counter sunscreen" D. "Wear form sitting clothing when going outside": A Protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. Stay in the shade, go outside in the early morning or evening to avoid the more intense sun rays to allow the pt to stay outside for a longer period -- B, do not remove any temporary ink markings when cleaning the skin until the entire course of radiation is complete C, apply only lotions that he provider prescribes. Chemical agents in sunscreen can cause irritation to the radiated skin D, wear loose fitting clothing over the treated area of skin. No buckles, belts, straps, or anything that binds or rubs the skin at the site

26. A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL: A Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI -- B, creatinine kinase MB elevates when there is injury to brain tissue, myocardial muscle, or skeletal muscle C, elevated cholesterol increases the risk for cardiovascular disease, but does not diagnose an MI D, this is within the expected reference range 27. A nurse is preparing to obtain blood cultures from a client's central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter A. Flush the lumen with heparin solution before each use B. Aspirate for blood return prior to each use C. Perform a 5 second scrub to the catheter hub before accessing the catheter D. Apply firm pressure to the syringe plunger when flushing the lumen: B -- A, flush the lumen of any CVC with 0.9% sodium chloride. The nurse can flush an implanted port with 5mL heparin 10 units / mL to prevent clots C, 15 second scrub D, apply slow, even pressure to the syringe plunger to flush the lumen, and immedi- ately stop if there is resistance. Use a 10mL syringe when flushing central catheters 28. A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first

A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10 D. Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min: D Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation and can indicate respiratory failure or shock, especially in pt who is postop.

29. A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan A. Suction the client's airway every 4 hours B. Limit the client's fluid intake to control secretions C. Provide the client with a high protein diet D. Administer the client's bronchodilator following each meal: C COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals -- A, do not suction COPD on a routine basis, only suction as necessary to clear secretions and maintain a patent airway B, encourage the intake of fluids at least 2L/day to help thin secretions D, administer bronchodilator 30 min prior to meals to reduce the risk of bron- chospasm 30. A nurse is administering parenteral nutrition to a client who has a history of heart failure. Which of the following manifestations indicates to the nurse that the client is experiencing fluid overload A. hypotension B. flattened neck veins C. nocturia

D. weight loss: C when the client is recumbent, the extracellular fluid enters the vascular system and increases the blood volume filtering through the kidneys, which increases urine production -- A, hypertension indicates fluid overload in a pt with heart failure B, distended neck veins indicates fluid overload in a pt with heart failure D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure

31. A nurse is teaching the caregiver of a client who has mild alzheimer's disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's disease A. Short term memory loss B. misplacement of household items C. Episodes of wandering D. loss of mobility: C Wandering occurs in the moderate stage of AD -- A, short term memory loss is an early stage of AD. In moderate stage, pt has impaired cognitive function and is disoriented B, misplacement of items is an early stage of AD. In moderate stage, pt develops a lack of awareness of their location and surroundings D, loss of mobility is severe stage of AD. in moderate stage, pt needs more assis- tance with mobility and ADLs but will still have some mobility 32. A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to heart failure. Which of the following statements by the client indicates an understanding of the teaching A. "I will limit my dietary sodium intake to 4 grams per day" B. "I should weigh myself once a week" C. "I plan to wait 2 hours after eating to take my walk" D. "I will take my diuretic before going to bed at night": C

To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise -- A, limit sodium to 2-3g per day to prevent fluid retention in a heart healthy diet B, weigh daily! Report a weight gain of more than 1.4kg (3lb) in 1 day or more than 2.3 kg (5lb) per week D, take diuretics in the morning to avoid having to get up during the night to void

33. A nurse is reviewing the laboratory reports of a client who has cirrhosis. Which of the following results should the nurse report to the provider imme- diately A. BUN 22 mg/dL B. Sodium 134 mEq/L C. Platelet count 18,000 mm D. WBC 4,500 mm: C The greatest risk to this client is injury from hemorrhage, and 18,000 is critically lower than the range of 150,000-400,000. A level <20,000 is a critical value representing thrombocytopenia and the potential for spontaneous bleeding 34. A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first A. Verify the label on the blood product with 2 client identifiers B. Check the client's medical record to verify the provider's prescription C. Flush the blood tubing with 0.9% sodium chloride D. Instruct the client to report itching or shortness of breath: B The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs 35. A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure A. "Avoid straining to have a bowel movement" B. "Avoid lying on your right side" C. "Avoid lifting objects that weigh more than 5 pounds" D. "Avoid sleeping with your head elevated": A

Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure

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B, instruct pt to lie on the unaffected side to decrease intraocular pressure C, avoid lifting objects that weight 4.5 kg (10lb) or more D, sleep with their head elevated. Avoid placing their head in a dependent position, as this increases intraocular pressure

36. A nurse is providing teaching about health promotion activities to an older adult client. Which of the following recommendations should the nurse include in the teaching A. "Maintain your dietary fat intake at 45% of your daily caloric intake" B. "Obtain 15 minutes of sunlight exposure 3 times per week" C. "Exercise for 30 minutes twice per week" D. "Decrease your fiber intake to less than 20 grams per day": B Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure adequate vitamin D production -- A, metabolism slows with age, so the client should maintain a dietary fat intake between 20-35% of daily caloric intake to prevent weight gain C, exercise 5 times per week for 30 min to improve strength and mobility D, increase dietary fiber containing foods to between 35-50 grams per day 37. A nurse is caring for a client who has an above the knee amputation related to trauma and is experiencing phantom limb pain. Which of the following medications should the nurse administer to treat the client's pain? A. Meloxicam B. Cyclobenzaprine C. Gabapentin D. Lidocaine: C phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain

--

A, meloxicam is an NSAID that helps treat mild to moderate nociceptive pain d/t tissue damage or inflammation B, cyclobenzaprine is a skeletal muscle relaxant that helps treat muscle spasms D, lidocaine is a topical anesthetic that provides surface anesthesia to relieve localized pain, itching and soreness

38. A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflam- matory response syndrome (SIRS)? A. WBC count 14,000/mm B. Platelets 110,000/ mm C. Lactic acid 19 mg/dL D. C reactive protein 2.8 mg/L: A WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS over- whelms the body's defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow's ability to produce neutrophils and WBCs, the WBC count can become extremely low -- B, slightly lower than the expected range of 150,000-400,000 , but this is an expected finding in SIRS C, lactic acid value of 19 is within the reference range of 5-20. We would see elevated lactic acid levels in SIRS D, 2.8 is within the expected range for C reactive protein of 1-3. Would expect it to be elevated in SIRS 39. A nurse is caring for a client who is receiving brachytherapy. Which of the following actions should the nurse take? A. Limit visitation time to 2 hr per day, per visitor B. Wear a dosimeter film badge when caring for the client C. Open the door toe the client's room when visitors are present D. Double bag bed linens and remove them daily from the client's room: B

the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation -- A, limit each visitor to 30 min per day to decrease the visitors exposure to radiation. Advise visitors to stay at least 6 feet from the radiation source located internally in the client C, keep the door closed to the pt room at all times to prevent radiation exposure to other clients and visitors D, keep bed linens in the client's room until the provider removes the radiation from the client. Once the client is no longer receiving radiation and all the radiation is accounted for, the nurse can remove linens using standard precautions.

40. A nurse is panning care for a client who has been newly diagnosed with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care A. Encourage liquid nutritional supplements B. Administer opioid medications via a PCA C. Assess for signs of hypercalcemia D. Administer hypotonic IV fluids: B pain mangement is important in the care of a client who has pancreatitis. Clients are most often started on opioid medication via PCA in the early stages of pancreatitis to mange pain -- A, remain NPO to rest pancreas in early stages of pancreatitis C, pacnreatitis causes hypocalcemia, monitor for chovstek's and trousseau's signs D, during acute period of pancreatitis, client is at risk of hypovolemia due to NPO status. Isotonic solutions (.9 NaCl) should be given to maintain fluid balance 41. A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is receiving heparin therapy by continuous IV infusion. Which of the following prescriptions should the nurse anticipate for an aPTT of 110 seconds A. Increase the rate of the heparin infusion

B. Stop the heparin infusion C. Administer vitamin K to the client D. Administer atropine to the client: B Therapeutic range of aPTT for client on heparin is 1.5-2.5 times the normal value. A value greater than 2.5 times the expected reference range of 20-40 seconds is critical! If the aPTT is > 100 seconds, anticipate a prescription to stop or decrease the heparin infusion rate -- C, vitamin K= warfarin antidote Protamine= heparin antidote

42. A nurse in the emergency department is caring for a client who has a traumatic brain injury (TBI). Which of the following assessment findings should the nurse recognize as a late manifestation of increased intracranial pressure (ICP) (select all that apply) A. Tachypnea B. Increased restlessness C. Bradycardia D. Asymmetric pupils E. Widened pulse pressure: C, D, E Late manifestations of ICP: -Bradypnea -Stuporous (requires painful stimuli to elicit a reaction) -Bradycardia -Asymmetric pupils -Widened pulse pressure 43. A nurse is caring for a client who has end stage liver disease and an active upper GI bleed. After inserting an NG tube, which of the following findings should the nurse expect A. Bright red drainage B. Dark brown drainage C. Off white drainage D. Greenish yellow drainage: A Red NG output indicates the client has an active upper GI bleed

--

B, dark brown NG output indicates intestinal obstruction C, off white drainage is an expected finding for NG drainage when the client does not have GI bleeding D, greenish yellow NG output contains bile and is an expected finding for NG drainage when the client does not have GI bleeding

44. A nurse is educating a group of clients about menopause. Which of the following information should the nurse include A. Limit exercise to 30 min, one to two times a week to reduce fatigue B. Hormone therapy (HT) is no longer used because of the risk of cancer C. Vaginal bleeding after 1 year without menses should be reported to the provider D. The use of complementary therapies to treat hot flashes should be avoid- ed: C Immediately report to the provider about any vaginal bleeding that occurs 1 year after menses have stopped. Vaginal bleeding after 1 year can indicate menopause has occurred, however, it can indicate a malignant process and the provider should be notified. -- A. exercise should not be limited B, HT is still somewhat controversial but can be used in small doses to treat moderate to severe manifestations of menopause. HT should be used for a short an amount of time as possible D, vitamins, herbal supplements, and meditation can help treat hot flashes 45. A nurse is reviewing the medical record of a client who is to undergo a surgical procedure. Which of the following findings indicates that the client is at risk for developing DVT A. BMI 38.6 B. History of asthma C. Use of glucosamine sulfate D. Hypothyroidism: A A BMI of 38.6 indicates the client is obese and is at a greater risk for developing DVT

as a surgical complication

B, does not increase risk of developing DVT C, glucosamine increses risk for bleeding, not a DVT D, hypothyroidism has a delayed response to healing, but not a risk for DVT

46. A nurse is caring for a client who has neutropenia following cyclosporine therapy. Which of the following actions should the nurse take? A. Monitor the client's vital signs every 8 hr B. Keep a designated blood pressure cuff in the client's room C. Inspect the client's mucous membranes daily D. Avoid the use of alcohol based hand sanitizers prior to client care: B Designate equipment to keep in the client's room to limit exposing the equipment to micro-organisms from other clients. Patients with neutropenia have an increased risk for infection and sepsis due to a reduction in their leukocyte count -- A, measure temperature at least every 4 hours to monitor for infection and sepsis C, inspect membranes at least every 8 hours for early detection of infection or bleeding D, proper hand hygiene is required prior to providing care or touching the client's belongings 47. A nurse is completing a preoperative assessment on a client who is scheduled for surgery in the morning. Which of the following findings should indicate to the nurse that the client is at risk for increased bleeding A. History of smoking B. Shellfish allergy C. Uses St John's wort D. Takes a garlic supplement: D Garlic supplements increase the client's risk for bleeding due to garlic's ability to inhibit blood clotting by decreasing platelet aggregation --

B, shellfish allergy indicates client is at risk for allergic reaction to povidone-iodine C, st johns wort can reduce the effectiveness of digoxin and calcium channel blockers, but does not increase risk for bleeding

48. A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the following findings should the nurse expect A. lethargy B. muscle spasms C. positive chvostek's sign D. shortened P-R interval: A 12.3 calcium indicates hypercalcemia (range is 9-10.5). Manifestations of hypercalcemia: muscle weakness, decreased deep tendon re- flexes, generalized weakness, fatigue, lethargy, confusion, weight loss, bone pain, cardiac dysrhythmias (shortened QT interval) and kidney stones Manifestations of hypocalcemia: muscle spasms, cramps, tetany, positive chvostek's sign (tap on clients face below and in front of ear, positive sign is twitching on one side of face) 49. A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse notes ventricular tachycardia on the ECG monitor. Which of the following actions should the nurse take A. Defibrillate the client B. Prepare the client for cardioversion C. Initiate CPR D. Administer digoxin: B cardioversion is a synchronized countershock that uses a pulse to help convert vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE -- A, defibrillation does not have a synchronized current and is not appropriate for a client who has stable Vtach and is responsive C, the nurse needs to assess ABCS and level of consciousness before beginning CPR. Because this patient is stable in vtach and is responsive, the pt does not need CPR D, the nurse should give an anti-dysrhythmic agent (amiodarone) to treat Vtach.

Digoxin increases ventricular irritability and would increase the clients risk of vfib after cardioversion

50. A nurse is providing discharge teaching to a client who has lithotripsy for calcium phosphate renal calculi. Which of the following instructions should the nurse give to the client A. Limit intake of animal protein to 6 oz per day B. Increase fluid intake to 1.5L/ day C. Expect pain in the kidneys and bladder D. Expect difficulty urinating for up to 1 week: A To prevent further kidney stones, the client should limit animal protein intake to 5 servings per week. Animal protein contains purine, which produces uric acid that can accumulate as stones in the kidney -- B, client should increase fluid intake to 3L/day C, pain in the kidneys and bladder is a manifestation of infection or formation of a stone D, blood in the urine is expected for 4-5 days, but any dysuria should be reported to the provider 51. A nurse is reviewing the ABG results of a client who is receiving total parenteral nutrition. The nurse notes a pH of 7.25, a bicarbonate of 18 mEq/L, and PaCO2 of 43 mm Hg. Which of the following acid base imbalances is the client experiencing A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis: C Low pH (acidosis) Normal PaCO2 Low bicarb (metabolic) 52. A nurse is caring for a client who is in the progressive stage of hypovolemic shock. Which of the following findings should the nurse expect A. Acidosis B. Bradycardia