ATI NCLEX Questions with Answers Tested and Verified Correct, Exams of Nursing

Download ATI NCLEX Questions with Answers Tested and Verified Correct and more Exams Nursing in PDF only on Docsity! 1 / 57 ATI NCLEX Questions with Answers Tested and Verified Correct 1.A client is exhibiting early signs of hemorrhage. Which findings should the nurse anticipate? 1. Cold, clammy skin 2. Heart rate 120/min 3. Weak, thready pulse 4. Blood pressure 80/60: 2. Heart rate 120/min 2.An older adult client reports recurring calf pain after walking one to two blocks that disappears with rest. The client has weak pedal pulses, and skin on the left lower leg is shiny and cool to the touch. Which nursing intervention is appropriate at this time? 1. Position the left leg dependently 2. Elevate the left leg above the heart 3. Immobilize the left leg to prevent further injury 4. Assess dorsiflexion and extension of the left foot: 1. Position the left leg dependently 3.A client who has just been diagnosed with rheumatoid arthritis is required to receive 3 months of methotrexate therapy. The nurse recognizes which of the following are adverse effects associated with the therapy? SATA 1. WBC 1,200 2. Weight gain 2.27 kg (5 lbs.) 3. Oral temperature of 37.2 (99) 2 / 57 4. Urine Specific Gravity 1.003 5. Platelets 5,000: 1. WBC 1,200 5. Platelets 5,000 4.A nurse prepares a staff in-service on incident reports. Which information should the nurse include? SATA 1. Risk management investigates the incident 2. A copy of report is placed in client's health record 3. Reports include description of incident and actions taken 4. Reports are confidential and not shared with noninvolved staff 5. Completion of report should be documented in the nurses' notes: 1. Risk management investigates the incident 3.Reports include description of incident and actions taken 4.Reports are confidential and not shared with noninvolved staff 5.A nurse is unsure of the proper technique when caring for a client who is prescribes enteral feedings. Which action should the nurse take? 1. Ask the charge nurse for step-by-step directions 2. Call the provider for specific instructions 3. Consult the unit procedure manual for guidance 4. Delegate task to a LPN to complete the feedings.: 3. Consult the unit procedure manual for guidance 5 / 57 4. Apply low dose oxygen via nasal cannula: 3. Assess the surgical incision site 11.A nurse arrives at a work site explosion. Which client should be triaged first? A client who has 1. Fixed pupils an agonal respirations 2. Burns to the face and respiratory stridor 3. Type 2 DM who is disoriented 4. A closed fracture reporting "a pain level of 3": 2. Burns to the face and respiratory stridor 12.A home health nurse is performing an admission assessment on a client who has a knee arthroplasty one week ago. Which client statement should concern the nurse the most? 1. "I am so glad to be of those blood thinners" 2. "I will keep a pillow under my knee when I am in bed" 3. "I am planning to use a wheelchair to help me get around" 4. "I plan to take ibuprofen instead of the prescribed hydrocodone with aceta- minophen for pain control": 1. "I am so glad to be of those blood thinners" 13. A nurse provides care for a client who has a chest tube. The nurse notes the chest tube has become disconnected from the chest drainage system. Which action should the nurse take? 1. Increase suction to the chest drainage system. 2. Reposition the client to a high-fowler's position 3. Apply to the client low-flow oxygen via nasal cannula 4. Immerse the end of the chest tube in a bottle of sterile water: 4. Immerse the end of the chest tube in a bottle of sterile water 6 / 57 14.A client receives a transfusion of packed RBC's and tells the nurse "My IV site is painful and looks like it is swollen" Which action should the nurse take? 1. Continue to monitor the site for signs of infection or infiltration 2. Double check the blood type of the unit of blood with another nurse 3. Start a new IV at another site and resume the transfusion at the new site 4. Discontinue the transfusion and send the remaining blood and tubing to the lab: 3. Start a new IV at another site and resume the transfusion at the new site 15.A client who has recently undergone surgery for a tracheostomy is now at home. The nurse recognizes a need for immediate intervention when the caregiver does which of the following? 1. Suctions intermittently for 15 seconds 2. Places an air humidifier at the bedside 3. Cuts a 4x4 gauze to put around the tracheostomy tube 4. Removes the ties before cleaning the tracheostomy: 4. Removes the ties before cleaning the tracheostomy 16.A nurse assigns four clients to the LPN. Which finding should the LPN immediately report to the nurse? A client 1. Receiving long-term IV abx who has a rash in his left groin 2. with baseline regular apical pulse of 88 who has an irregular apical pulse of 120 today 3. Who has a recent diagnosis of terminal cancer and refuses to eat or partic- ipate in hygiene care. 7 / 57 4. eight hours post laparoscopic surgery who reports abdominal distention and shoulder pain.: 2. with baseline regular apical pulse of 88 who has an irregular apical pulse of 120 today 17.A nurse plans to administer the following medication. Which medication should the nurse administer first? 1. A scheduled IV abx for a client with resolving pneumonia. 2. Pain medication to a client who rates their pain a 4-5 on a 0-10 scale 3. An antidiarrheal for a client with one diarrhea stool in the last hour 4. The antipyretic to a client with a temperature of 100.7 (38.2): 1. A scheduled IV abx for a client with resolving pneumonia. 18.A nurse cares for a group of clients. Which information can be disclosed about a client? 1. HIV status to the client's coworkers 2. Stage IV cancer diagnosis to the client's family 3. Uncontrolled seizure disorder to DMV 4. Alcohol detoxification recovery status to client's employer: 3. Uncontrolled seizure disorder to DMV 19.A nurse notes the 16-year old signed the consent form for a surgical procedure. Which action should be first? 1. Cancel the surgical procedure until a valid consent form can be signed. 2. Verify the signature is witnessed appropriately and send the client for the surgery. 3. Determine whether the client meets legal requirements to sign the consent form. 4. Locate the client's patent or guardian to sign the consent form.: 3. Determine whether the client 10 / 57 1. The time required to restart the IV if site is compromised. 2. The current staffing level of the nursing unit. 3. The presence of family members at the bedside. 4. The reason the client may potentially pull out the IV.: 4. The reason the client may potentially pull out the IV. 26.A nurse cares for a client who is receiving chemotherapy. Which action should be implemented if the IV tubing separates? 1. Notify housekeeping to clean the spilled solution 2. Complete incident report about the spill of chemotherapy. 3. Use towel to clean solution and dispose in a biohazard bag. 4. Obtain chemotherapy spill kit and use according to directions.: 4. Obtain chemotherapy spill kit and use according to directions. 27.After eating lunch, a client who is immobile requests to be turned to the right side. Which actions should the nurse take? (place steps in order) 1. Flex left knee and roll toward the nurse 2. Place pillow under head and neck 3. Position arms 4. Place supine and move to side of bed 5. Position pillows to maintain alignment 6. Move right shoulder forward: 4. Place supine and move to side of bed. 1.Flex left knee and roll toward the nurse 11 / 57 2.Place pillow under the head and neck 6. Move right shoulder forward 5.Position pillows to maintain alignment 3.Position arms 28.A nurse instructs the use o a cane to a client with left-sided weakness. Which instruction should be included? 1. Place the cane in the left hand. 2. Hold the cane on the right side and advance left foot forward. 3. Advance the cane 12-16 inches (30-40cm) with each step 4. Keep elbow flexed and move the right foot forward initially.: 2. Hold the cane on the right side and advance left foot forward. 29.A nurse provides discharge teaching to a client who has acquired immun- odeficiency syndrome. Which spill management technique should be includ- ed? 1. Clean area with detergent and rinse with ammonia 2. Disinfect area with 10% bleach solution after initial cleaning. 3. Clean area thoroughly with cold water and allow to air dry. 4. Disinfect area with 70% isopropyl alcohol after initial cleaning.: 2. Disinfect area with 10% bleach solution after initial cleaning. 30.A nurse evaluates room assignments. Which room assignments (room- mates) are 12 / 57 appropriate? SATA. 1. HF exacerbation and hemoccult positive stool 2. Disseminated shingles and suspected TB 3. Accessed implanted port and Necrotizing fasciitis, group a beta hemolytic streptococcus 4. HIV positive WBC 5200 and Hep B positive 5. Ulcerative Colitis and Hep A positive: 1. HF exacerbation and hemoccult positive stool 4.HIV positive WBC 5200 and Hep B positive 5.Ulcerative Colitis and Hep A positive 31.A nurse cares for a client 6 hours post total laryngectomy who has history of Hepatitis C and HIV. Which equipment is recommended during direct care? 1. Gloves only 2. Gloves and gown 3. Gloves, gown and mask 4. Gloves, gown, mask, goggles: 4. Gloves, gown, mask, goggles 32.A nurse evaluates room assignments. Which room assignments require immediate modification? 1. COPD exacerbation on prednisone and Positive C. Diff 2. Positive VRE urine culture in client with urinary catheter and Acute MI post resuscitation 3. Positive influenza B and positive influenza B 4. Positive MRSA sputum and Post-op total knee replacement: 4. Positive MRSA sputum and Post-op 15 / 57 3.Durable power of attorney 4. Initiation of diagnostic assessments 6. Prescription for do not resuscitate (DNR) 36.A nurse plans care for a client who is diagnosed with a CVA. Which members of the interprofessional team should participate in planning care? SATA 1. Dietician 2. Hospice Nurse 3. Speech Therapist 4. Physical Therapist 5. Rapid Response Team: 1. Dietician 3.Speech Therapist 4.Physical Therapist 37.A nurse provides care for a client who recently had a tracheostomy placed. Which equipment should be placed at the bedside? SATA 1. Nasal cannula 2. O2 set up 3. Suction equipment 4. Manual ventilation bag 5. Two tracheostomy tubes: 2. O2 set up 16 / 57 3.Suction equipment 4.Manual ventilation bag 5.Two tracheostomy tubes 38.A client plans to leave the facility "Against Medical Advice". Which actions should the nurse implement? SATA 1. Contact the provider 2. Notify the security department 3. Ask the client to sign an informed consent. 4. Obtain a discharge prescription immediately 5. Inform the client of complications that may occur without treatment: 1. Contact the provider 5. Inform the client of complications that may occur without treatment 39.A community health nurse provides teaching about the Zika virus to clients who live in an at risk area. What information should be included? SATA 1. Flu-like symptoms should be reported to HCP 2. Vaccination is recommended for prevention. 3. The virus can spread through sexual intercourse 4. Infection during pregnancy can cause severe fetal defects 5. Mosquito repellent should be applied when going outdoors.: 1. Flu-like symptoms should be reported to HCP 3.The virus can spread through sexual intercourse 17 / 57 4. Infection during pregnancy can cause severe fetal defects 5.Mosquito repellent should be applied when going outdoors. 40.A case management nurse plans discharge for an older adult. Which ac- tions reflect effective care coordination? SATA 1. Resolving the plan of care 2. Arranging home health services 3. Administering scheduled medications 4. Performing nasogastric tube insertion 5. Facilitating referrals for community services 6. Scheduling follow-up provider appointments.: 1. Resolving the plan of care 2.Arranging home health services 5.Facilitating referrals for community services 6.Scheduling follow-up provider appointments. 41.A nurse provides care for a client who has recently returned from West Africa. Which symptoms should be reported immediately? SATA 1. Fever 2. Dysuria 3. Epistaxis 20 / 57 53.A nurse provides teaching to a client who is prescribed atorvastatin. Which statement indicated effective instruction? 1. "I do not need to modify my diet" 2. "I plan to take the medication with lunch" 3. "I will notify the provider if muscle aches occur" 4. "I will check renal function labs every 6 mos": 3. "I will notify the provider if muscle aches occur" 54.A nurse teaches a client the proper use of a metered dose inhaler. Which sequence should the nurse demonstrate to maximize medication effective- ness? Place the following steps in the proper order. 1. Inhale and depress the canister simultaneously 2. Place between teeth, and seal lips around inhaler. 3. Shake the metered dose inhaler 4. Inhale and exhale completely. 5. Remove mouthpiece cover 6. Hold breath for 5-10 seconds, then exhale slowly.: 5. Remove mouthpiece cover 3. Shake the metered dose inhaler 4. Inhale and exhale completely. 2. Place between teeth, and seal lips around inhaler. 1. Inhale and depress the canister simultaneously 21 / 57 6. Hold breath for 5-10 seconds, then exhale slowly. 55.A nurse provides teaching to a client prescribed two sprays of desmo- pressin acetate per nostrils as directed. Which instruction should be includ- ed? 1. Discard medication bottle every 7 day. 2. Instill both sprays into same nostril daily. 3. Sit upright for 30 min after administration. 4. Store unused medication in the refrigerator.: 4. Store unused medication in the refrigerator. 56.A nurse cares for a client receiving levothyroxine. Which findings indicate the medication dosage should be increased? SATA 1. Tachycardia 2. Hypotension 3. Paresthesia 4. Constipation 5. Excessive sweating 6. Decreased appetite: 2. Hypotension 3.Paresthesia 4.Constipation 6. Decreased appetite 57.A nurse provides teaching to a client who is prescribed omeprazole. Which statement indicates a 22 / 57 need for further instruction? 1. "Ibuprofen should be avoided" 2. "I will eat additional dairy products" 3. "This medication is taken with each meal" 4. "My provider will be called if I have a cough": 3. "This medication is taken with each meal" 58.A nurse cares for a client with DM who reports labia irritation and vaginal cheese-like discharge. Which of the following medications should be expect- ed? 1. Imiquimod 2. Ceftriaxone 3. Fluconazole 4. Metronidazole: 3. Fluconazole 59.A nurse provides discharge teaching to a client receiving rifampin. Which instructions should be included regarding the use of contact lenses? 1. "Wait two weeks until you have established a medication level" 2. "It's inadvisable to wear plastic contact lenses during treatment" 3. "It might be best to wait until you have completed treatment" 4. "Avoid consuming alcohol while you are taking the medication": 2. "It's inadvisable to wear plastic contact lenses during treatment" 60. A nurse provides medication teaching to a client who is taking ibandronate. Which instruction should the nurse question? 1. "Drink a full glass of juice when you take this medication" 25 / 57 65.A nurse admits a client who has dehydration secondary to vomiting. Which lab values should the nurse expect to be elevated? SATA. 1. Serum pH 2. Hematocrit 3. Urine osmolarity 4. Serum potassium 5. Urine specific gravity: 1. Serum pH 2. Hematocrit 3. Urine osmolarity 5. Urine specific gravity 66.A nurse admits a client who has a potassium level of 3.2 mEq/L. Which response does the nurse recognize as therapeutic to the prescribed KCL 40 mEq/L IV infusion over 4 hours? SATA. 26 / 57 1. Trousseau's sign becomes negative 2. Reports leg cramps are no longer present 3. Serum potassium is 3.6 mEq/L after infusion 4. HR decreased from 110 bpm to 85 bpm 5. Peaked T-waves disappeared from electrocardiogram: 2. Reports leg cramps are no longer present 3. Serum potassium is 3.6 mEq/L after infusion 67.An older adult client is receiving IV fluids at 150 mL/hr and suddenly reports, "I feel like I am suffocating." Respirations are labored at 40/min and crackles are auscultated bilaterally. Which actions should the nurse take? SATA 1. Increase IV fluids 2. Administer oxygen 3. Assess jugular vein 4. Administer PRN dose of furosemide. 5. Monitor HR and BP 6. Place in modified Trendelenburg position: 2. Administer oxygen 3.Assess jugular vein 4.Administer PRN dose of furosemide. 5.Monitor HR and BP 27 / 57 68.A client has a pulmonary embolism. Initial treatment includes 40% oxygen via Venturi mask, IV heparin therapy, and bed rest. Which finding should indicated to the nurse therapy is effective? 1. PaO2 75 mmHg 2. aPTT 70 seconds 3. CT scan of chest positive for infiltrate 4. Calf edema and erythema are resolved.: 2. aPTT 70 seconds 69.A nurse cares for a client who has a chest tube and notices that tidaling in the water seal chamber has stopped. Which complication is the most likely cause? 1. Obstruction is present in the tubing. 2. Crackles are heard upon auscultation. 3. Water level in suction chamber is low. 4. Air is no longer present in the pleural space.: 1. Obstruction is present in the tubing. 70.A client is receiving mechanical ventilation and the high-pressure alarm sounds. Which action should the nurse implement? 1. Check for a leak or break in the ventilator system. 2. Administer a sedative to decrease the client's anxiety. 3. Assess the client to determine the need for suctioning. 4. Check for air escaping around the cuff of the endotracheal tube.: 3. Assess the client to determine the need for suctioning. 30 / 57 6. Canned green beans.: 3. Cream of wheat 4. Puffed rice cereal 6. Canned green beans. 76.A nurse provides discharge teaching to a client regarding colostomy care. Which instructions should be included? SATA 1. "Clip hair surrounding the peristomal site" 2. "Empty colostomy bag when one third full" 3. "Add cranberry juice and yogurt to your diet" 4. "apply moisturizing soap to cleanse skin surrounding stoma" 5. "avoid use of stoma powder, if peristomal skin becomes raw": 1. "Clip hair surrounding the peristomal site" 2."Empty colostomy bag when one third full" 3."Add cranberry juice and yogurt to your diet" 77.A client who has ulcerative colitis is scheduled for discharge following placement of a permanent ileostomy. Which instructions should the nurse include? SATA 1. Take enteric-coated medications. 2. Notify the provider if no stool in 24 hours. 3. Avoid raw cabbage, nuts, and popcorn. 4. Change the entire pouch system every 3 to 7 days. 5. Include an adequate amount of sodium and water in the diet. 6. Assume knee-chest position if abdominal cramping occurs.: 3. Avoid raw cabbage, nuts, and 31 / 57 popcorn. 4.Change the entire pouch system every 3 to 7 days. 5. Include an adequate amount of sodium and water in the diet. 6.Assume knee-chest position if abdominal cramping occurs. 78.A client who has cirrhosis is admitted with an elevated ammonia level. The nurse should request a nutritional consult if the client reports which dietary change? 1. Eliminating protein intake 2. Reducing salt consumption 3. Increasing carbohydrate foods 4. Including a moderate amount of fat.: 1. Eliminating protein intake 32 / 57 79.A nurse cares for a client who has Syndrome of Inappropriate Antidiuretic Hormone (SIADH) and a serum sodium level of 116 mEq/L. Which action should be implemented? 1. Prepare D5W IV infusion 2. Initiate seizure precautions. 3. Obtain 12-lead electrocardiogram. 4. Monitor client's serum osmolarity.: 2. Initiate seizure precautions. 80.A nurse reviews results for a client diagnosed with hypoparathyroidism. Which laboratory values should be expected? SATA. 1. Sodium 140 mEq/L 2. Potassium 3.6 mEq/L 3. Total calcium 7.1 mg/dL 4. Phosphorus 6.2 mg/dL 5. Fasting glucose 100mg/dL: 3. Total calcium 7.1 mg/dL 4. Phosphorus 6.2 mg/dL 81.Place the following actions for blood administration in the correct order: 1. Complete transfusion within 4 hours after unit leaves blood bank 2. Obtain unit of PRBC's from blood bank. 3. Verify client ID & compatibility of blood at bedside with 2nd nurse. 35 / 57 88.Class: Narcotic- Centrally Acting Analgesic Indication: Moderate to severe pain Low incidence of abuse Side Effect: Sedation, dizziness, HA, dry mouth, constipation: Tramadol 89.Class: Ergot alkaloid Indication: Postpartum bleeding Side Effects: Nausea, HA, HTN: Methylergonovine 90.Class: Antineoplastic; Immunosuppressant Indications: RA, cancer, psoriasis, Crohn's Side Effects: Nausea, elevated LFT's, fatigue: Methotrexate 91.Class: Anticonvulsant Indication: Partial seizures, neuropathic pain Side Effects: Drowsiness, dizziness, fatigue: Gabapentin 92.Class: Organic Nitrate Indication: Angina Side Effects: HA, hypotension, tachycardia: Nitroglycerin 93.Class: Uterine Stimulant Indication: Induce or augment labor; postpartum hemorrhage Side Effect: Tachysystole, uterine rupture, elevated BP, fetal hypoxia: Oxytocin 94.Class: 1st generation NSAID Indication: analgesia for mild to moderate pain such as OA and RA Side Effects: Dyspepsia, abdominal pain, nausea, long-term use, GI bleed- ing/perforation: Meloxicam 36 / 57 95.Class: Atypical antipsychotic Indications: Schizophrenia, acute bipolar mania, autism Side Effects: weight gain, dyslipidemia, diabetes: Risperidone 96.Class: Glucocorticoid Indication: Inflammation Side Effects: Euphoria, Infection, Cushing's syndrome: Methylprednisolone 97.Class: Glucocorticoid/bronchodilator Indications: Prophylaxis in chronic restrictive airway diseases (asthma, COPD) Side Effects: GI upset, infection: Budesonide/formoterol 98.Class: Uricosuric Indication: Chronic gout Side Effects: Nausea, Hypersensitivity, fever, nausea, and rash: Allopurinol 99.Class: Antibacterial (glycopeptide) Indication: Clostridium difficile, MRSA Side Effects: Nephrotoxicity, "red man syndrome": Vancomycin 100. Class: Antibiotic Indication: Bacterial Infection Side Effect: GI upset, leukopenia: Piperacillin/tazobactam 101. Is piperacillin/tazobactam okay to give to someone with an allergy to penicillin?: No! 102. When a patient is taking vancomycin, what labs should the nurse monitor for signs of nephrotoxicity?: BUN 10-20 Serum Creatinine 0.6-1.2 103. When a patient is taking Allopurinol, what should the nurse do if the patient 37 / 57 complains of nausea?: Give med with food 104. Why does taking Budesonide/formoterol place the client at risk for infec- tion?: Immunosuppression 105. What are the symptoms of Cushing's syndrome?: Buffalo hump, moon face, general weakness, hypokalemia, hyperglycemia, hypernatremia 106. Why does the client using risperidone need routine blood tests?: Monitor for elevated cholesterol and hyperglycemia 107. What may decrease the risk of ulcer formation when taking Meloxicam?: - Administer a PPI or H2 receptor antagonist to decrease risk of ulcer formation. Take meloxicam with food or 8oz of water or milk. 108. What is a tocolytic?: The opposite of oxytocin: relaxes myometrium 109. What safety precautions should the nurse implement for a patient taking nitroglycerin?: Fall risk (vasodilation causes dizziness) 110. Why is gabapentin most effective 3x/day?: Doses peak in 2-3 hours 111. How does methotrexate improve symptoms of RA?: Immunosuppression 112. What places a woman at risk for postpartum hemorrhage?: Uterine atony, laceration, impaired maternal clotting, retained placenta fragments 113. Tramadol should not be administered to a client who has a history of .: Seizure disorder 114. Is detemir given prior to meals to control postprandial blood glucose?: - No, peak time is 6-8 hours 40 / 57 1. Lethargy 2. Mild thirst 3. Dehydration 4. Blurred vision 5. Slurred speech: 1. Lethargy 3.Dehydration 5. Slurred speech 123. A nurse plans discharge for a client who has dependent personality disorder. Which findings indicate a desired response to therapy? SATA 1. Demonstrates empathy for others 2. Creates a daily list of short-term goals. 3. Gathers information before decision-making 4. Self-administers diazepam to control anger 5. Manages delusions of grandiosity with quetiapine.: 2. Creates a daily list of short-term goals. 3.Gathers information before decision-making 41 / 57 124. A nurse cares for a client who is admitted for treatment of opioid ad- diction. Which manifestations of opioid withdrawal should the nurse expect? SATA 1. Fever 2. Euphoria 3. Somnolence 4. Diaphoresis 5. Irritability 6. Vomiting: 1. Fever 4.Diaphoresis 5. Irritability 6.Vomiting 125. A nurse cares for a client who has been admitted for detoxification of CNS stimulant addiction. Which finding should be expected eight hours after admission? 1. Tachycardia 2. Increased appetite 3. Tonic-clonic seizures 4. Paranoia with delusions: 2. Increased appetite 126. A nurse admits a client with anorexia nervosa who has had a 14 pound weight loss in 42 / 57 the past two weeks. Which action should be the priority? 1. Explore client's feelings 2. Remain with client after meals 3. Foster a therapeutic relationship 4. Initiate IV fluid therapy as prescribed: 4. Initiate IV fluid therapy as prescribed 127. A nurse cares for an older client who has unexplained weight loss and extensive bruising. Which action should be the priority? 1. Use short, simple sentences 2. Refer client to medical social worker 3. Maintain client's self-esteem and dignity 4. Collect physical data and communicate findings to charge nurse.: 4. Collect physical data and communicate findings to charge nurse. 128. A nurse cares for a client who has PTSD. Which actions should the nurse implement? SATA 1. Reinforce behavioral therapy 2. Allow expression of traumatic event 3. Administer haloperidol orally PRN 4. Encourage family participation in therapy 5. Approach client in calm, reassuring manner.: 2. Allow expression of traumatic event 45 / 57 3. Infant nurses every 3 hours during the day 4. Keeps infant to each breast for 15 minutes: 2. Given a bottle during the night 135. A nurse cares for a client who has Rh negative blood and delivered a newborn with Rh positive blood. Which maternal lab should be monitored to determine RhoGAM administration? 1. Platelets 2. Hemoglobin 3. Direct Coombs' 4. Indirect Coombs': 4. Indirect Coombs' 136. A nurse cares for a client who is 2 hours postpartum. Which finding should be of most concern? 1. Two perineal pads saturated since delivery. 2. Fundus 1 cm above the level of the umbilicus. 3. Painful uterine contractions while infant breastfeeds 4. Large amount of dark blood from vagina when standing the first time.: 1. Two perineal pads saturated since delivery. 137. A client who is 1 hour postpartum presses the call light and reports "a lot of blood and clots are coming from my vagina" What should the nurse do first? 1. Check time and amount of last void 2. Determine uterine firmness and location 3. Assess for orthostatic changes in vital signs 4. Examine the episiotomy for signs of bleeding: 2. Determine uterine firmness and location 46 / 57 138. A nurse cares for a client 48 hours postpartum who has developed endometritis. Which interventions should the nurse anticipate? SATA 1. Lochia assessment 2. Sitz bath as needed 3. Cephalosporin IV therapy 4. Perineal pads changed every 6 hours 5. Abdominal binder when ambulating.: 1. Lochia assessment 2.Sitz bath as needed 3.Cephalosporin IV therapy 139. A nurse assigns an Apgar score of 8 at one minute. Which action should the nurse take next? 47 / 57 1. Begin CPR 2. Suction the nose then mouth via bulb syringe 3. Transfer to the NICU 4. Implement routine newborn care: 140. The axillary temperature of the newborn client is 35.8 C (96.4 F). Which finding should indicate to the nurse the presence of cold stress? 1. Apical heart rate of 160/min with shivering. 2. Moist skin with vernix caseosa in skin folds. 3. Cool, cyanotic extremities with warm trunk. 4. Respirations 35/min with sternal retractions.: 3. Cool, cyanotic extremities with warm trunk. 141. A nurse cares for a newborn delivered at 41 weeks gestation who is jittery with a weak cry. Which action should be first? 1. Send a specimen for a serum glucose. 2. Perform a heel-stick for glucose levels. 3. Request provider to order a drug screen. 4. Administer soy based formula to newborn.: 2. Perform a heel-stick for glucose levels. 142. A nurse plans to teach a parenting class. Which measure should be included to prevent the most common cause of death for infants and children? 1. Avoid unknown animals 50 / 57 6. BP 78/52 147. A nurse receives report on a group of clients. Which client should be assessed first? 1. An infant with an axillary temperature of 100.1 (37.8) who is tugging at left ear. 2. A school-ages client with sore throat who is sitting upright in tripod position and drooling. 3. A pre-school aged child with harsh cough, expiratory wheezes, and milk intercostal retractions. 4. A toddler with barking cough, infrequent inspiratory stridor, and oxygen saturation 94% on RA.: 2. A school-ages client with sore throat who is sitting upright in tripod position and drooling. 148. A nurse cares for a toddler who has glomerulonephritis. Which interven- tion should be the priority of care? 1. Record intake/output every 2 hours 2. Assess blood pressure every 1 hour. 3. Maintain diet with reduced sodium content. 4. Plan activities to allow for frequent rest periods.: 2. Assess blood pressure every 1 hour. 149. A nurse cares for an infant who has cystic fibrosis and is receiving pancrelipase powder. Which finding is a desired effect of the medication? 1. Clear lung breath sounds. 2. Skin is free of salt crystals. 3. Steady weight/height gain. 51 / 57 4. Fewer respiratory infections.: 3. Steady weight/height gain. 150. Class: Platelet Aggregation Inhibitor Indications: Prevent stenosis after cardiac stent placement, MI, and CVA. Side Effects: Abdominal pain, dyspepsia, diarrhea, bleeding: Clopidogrel 151. What would you assess in a client taking clopidogrel?: H & H, epistaxis, bruising and bleeding 152. Class: mood stabilizer Indication: bipolar disorder Side effects: Anorexia, confusion, thirst: Lithium 153. What are the signs of Lithium Toxicity?: Vomiting, Diarrhea, slurred speech 154. Class: Antipsychotic Indication: Schizophrenia, acute psychosis, Tourette's Side Effects: Mild leukopenia, EPS (high risk), TD, laryngospasm, respiratory depression, NMS: Haloperidol 155. What are the symptoms of Neuroleptic Malignant Syndrome (NMS)?: - Rigidity, sudden high fever, BP instability 156. Class: Sedative-hypnotic Indication: Insomnia Side Effects: Daytime fatigue and drowsiness, dizziness: Zolpidem 157. Class: Proton Pump Inhibitor Indication: GERD, gastric ulcers Side effects: N/V, abdominal pain: Esomeprazole 158. When is esomeprazole taken?: one hour prior to eating 52 / 57 159. Class: Antidysrhythmic Indication: A-fib, V-fib, V-tach Side Effects: Pulmonary toxicity, liver injury, heart block: Amiodarone 160. What findings indicate respiratory failure?: Dyspnea, diminished breath sounds, rales, friction rub 161. Class: Atypical antipsychotic Indication: Schizophrenia, major depressive disorder, autism, bipolar mania Side effects: Anxiety, insomnia, agitation, EPS (low risk): Aripiprazole 162. What mental health safety concerns are associated with Aripiprazole?: - Increased depression, suicidal ideation 163. Class: Biphosphonate Indication: Osteoporosis Side Effects: Bone pain, leg cramps, colitis: Risedronate 164. Class: growth factor Indication: anemia (CKD/Chemotherapy) Side effects: HTN, thrombotic stroke, clotting of AV fistula: Epoetin 165. What labs should the nurse monitor when the patient is on Epoetin?: - H&H, CBC, BUN, potassium, iron 166. Class: Insulin (rapid acting) Indication: Type 1 and type 2 diabetes Side effects: hypoglycemia: Aspart 55 / 57 Indications: Prophylaxis for asthma, allergic rhinitis SE: Oropharyngeal candidiasis, horseness: Fluticasone 186. How often should the client use fluticasone?: Daily 187. Class: Beta blocker/Antihypertensive Indication: HTN, angina, dysrhythmias, MI, acute anxiety SE: Bradycardia, AV heart block, heart failure, bronchoconstriction: Propra- nolol 188. What is the black box warning for propranolol?: Exacerbation of angina/MI if abruptly discontinued 189. Class: Cholinesterase inhibitor Indication: Mild to severe Alzheimer's Disease SE: Nausea, vomiting, diarrhea, GI bleeding, anorexia, dizziness, bronchocon- striction, bradycardia: Donepezil 190. What important teaching is needed for a client taking Donepezil?: Take it at bedtime, may cause vivid unusual dreams, implement safety precautions 191. Class: ACE inhibitor Indication: HTN, heart failure, acute MI SE: Persistent dry cough, hyperkalemia, renal failure, angioedema: Lisinopril 192. Should women use a reliable form of birth control while taking Lisino- pril?: yes, black box warning of being associated with fetal injury/death 193. Class: Antibiotic Indication: Tuberculosis SE: Hepatotoxicity, causes body secretions to turn orange: Rifampin 56 / 57 194. How would the nurse assess liver toxicity?: Increased LFT, jaundice, dark urine, light stools, RUQ pain 195. Class: Anticoagulant Indication: DVT prevention, ischemia prevention in unstable angina and MI SE: Bleeding, neurological injury: Enoxaparin 196. What is the antidote for enoxaparin?: Protamine sulfate 197. Class: Antidysrhythmic Indications: Paroxysmal SVT SE: Bradycardia, dyspnea, hypotension, flushing, chest discomfort: Adenosine 198. What client outcome should the nurse expect after giving a client Adeno- sine?: Conversion to normal sinus rhythm 199. Class: 5-alpha-reductase inhibitor Indication: Benign prostatic hyperplasia SE: decreased ejaculate and libido: Dutasteride 200. Should clients using dutasteride donate blood?: No, it is teratogenic 201. Class: Anticoagulant Indication: Prophylaxis for thrombosis, TIAs and MI SE: Black box warning: Serious/fatal bleeding events: Warfarin 202. should foods containing vitamin K be avoided while taking warfarin?: No, consistent intake recommended 203. Class: Antiepileptic Indication: Seizures SE: Gingival hyperplasia, thrombocytopenia: Phenytoin 57 / 57 204. Is a client taking Phenytoin susceptible to Stevens Johnson Syndrome?- : Yes, (flu like s/sx, skin rash) Instruct client to stop taking medication and notify provider