ATI units 2 3 8 - Med surge PDF

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Med surge...

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Units 2 & 3 Practice-ATI

1. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature

2. A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

3. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

4. 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." B. "A pharmacist is the person to answer that question." C. "Heparin does not dissolve clots. It stops new clots from forming."

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Units 2 & 3 Practice-ATI D. "The oral medication you will take after this IV will dissolve the clot."

5. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

6. 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 B. Hypotension C. Ototoxicity D. Muscle pain

7. A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? A. Hemoglobin (Hgb) B. Prothrombin time (PT) C. Bleeding time D. Activated partial thromboplastin time (aPTT)

8. A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? A. Stop the infusion of blood. B. Inform the provider.

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Units 2 & 3 Practice-ATI C. Obtain a urine specimen. D. Notify the laboratory.

9. A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. "These tests help determine the degree of damage to the heart tissues." B. "Cardiac enzymes will identify the location of the MI." C. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." D. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

10.A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? A. Ambulate the client four times per day. B. Encourage the client to consume clear liquids. C. Provide frequent oral and nares care. D. Keep the client in a supine position.

11.A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

12.A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub

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Units 2 & 3 Practice-ATI C. The third heart sound (S3) D. A split second heart sound S2

13.A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy B. Laparoscopic appendectomy C. Hip arthroplasty D. Cataract extraction

14.A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect? A. Febrile B. Allergic C. Acute pain D. Hemolytic

15.A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first? A. Notify the client's provider. B. Check the client's vital signs. C. Fill out an occurrence form. D. Administer the medication to the correct client.

16.A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? A. Prevents dysrhythmias

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Units 2 & 3 Practice-ATI B. Slows intestinal motility C. Dissolves blood clots D. Relieves pain

17.A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypotension B. Bradycardia C. Clubbing of the nail beds D. Weak pulses F. Murmur

18.A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Answers cannot be displayed for this alternate item format.

19.A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform? A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis. B. Maintain constant observation while the balloons are inflated. C. Suction the tube every 2 hr and as needed to maintain patency. D. Keep the head of the bed flat at all times to prevent the development of shock.

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Units 2 & 3 Practice-ATI

20.A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr

21.A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client has a history of hypothyroidism. B. The client has a history of bronchial asthma. C. The client has a history of hypertension. D. The client has a history of migraine headaches.

22.A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Different apical and radial pulses. C. Differences between oral and axillary temperatures. D. Differences in upper and lower lung sounds.

23.A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave. (Selectable areas, or "Hot Spots," can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)

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Units 2 & 3 Practice-ATI

Answers cannot be displayed for this alternate item format.

24.A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching? A. "I have started taking ginger root to treat my joint stiffness." B. "I take this medication at the same time each day." C. "I eat a green salad every night with dinner." D. "I had my INR checked three weeks ago."

25.A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving a vitamin K deficiency."

26.A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect? A. Excessive thrombosis and bleeding B. Progressive increase in platelet production C. Immediate sodium and fluid retention D. Increased clotting factors

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Units 2 & 3 Practice-ATI

27.A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? A. The laboratory values are within the expected reference range. B. The laboratory values are prolonged. C. The laboratory values are decreased. D. The laboratory values are the same as the previous test values.

28.A nurse enters a client’s room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A. Call the emergency response team. B. Seek immediate help from the risk manager. C. Call the provider for a stat DNR order. D. Respect the family’s wishes and do nothing.

29.A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? A. "I will have my child rest." B. "I will elevate the affected part." C. "I will compress the site." D. "I will apply heat."

30.A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? A. A raised red rash around the fistula site B. Pain in the right arm proximal to the fistula site C. Cold and numb numbness distal to the fistula site D. Foul-smelling drainage from the fistula site

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Units 2 & 3 Practice-ATI

31.A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching? A. Mild nosebleeds are common during initial treatment. B. Use an electric razor while on this medication. C. If a dose of the medication is missed, double the dose at the next scheduled time. D. Increase fiber intake to reduce the adverse effect of constipation.

32.A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia B. Ataxia C. Photosensitivity D. Jaundice

33.A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased B. Cardiac output is reduced C. Apical heart rate is increased D. Urine output is reduced

34.A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? A. "A headache is an indication of an allergy to the medication." B. "A headache is an expected adverse effect of the medication." C. "A headache indicates tolerance to the medication." D. "A headache is likely due to the anxiety about the chest pain."

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Units 2 & 3 Practice-ATI

35.A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? A. Apply a new transdermal patch once a week. B. Apply the transdermal patch in the morning. C. Apply the transdermal patch in the same location as the previous patch. D. Apply a new transdermal patch when chest pain is experienced.

36.A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? A. Vitamin K B. Protamine sulfate C. Acetylcysteine D. Deferasirox

37.A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? A. "Take this medication after each meal and at bedtime." B. "Take one tablet every 15 min during an acute attack." C. "Take one tablet at the first indication of chest pain." D. "Take this medication with 8 ounces of water."

38.A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include? A. "Limit your fluid intake to meal times." B. "Do not take this medication on an empty stomach." C. "Increase your daily intake of dietary fiber." D. "You can expect swelling of the ankles while taking this medication."

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Units 2 & 3 Practice-ATI 39.A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? A. Take aspirin if headaches develop. B. Eat foods that contain plenty of potassium. C. Expect some swelling in the hands and feet. D. Take the medication at bedtime.

40.A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client’s restored rhythm is symptomatic bradycardia? A. Epinephrine B. Magnesium C. Atropine D. Sodium bicarbonate

41.A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take? A. Administer another nitroglycerin tablet. B. Initiate a peripheral IV. C. Call the Rapid Response Team. D. Obtain an ECG.

42.A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer? A. Epinephrine B. Atropine C. Protamine D. Vitamin K

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Units 2 & 3 Practice-ATI 43.A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? A. Withholding the medication if the heart rate is above 100/min B. Instructing the client to eat foods that are low in potassium C. Measuring apical pulse rate for 30 seconds before administration D. Evaluating the client for nausea, vomiting, and anorexia

44.A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing B. Dyspnea C. Bradycardia D. Vomiting

45.A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll dial 911 if I still have pain after taking 3 nitroglycerin tablets 5 minutes apart." B. "I'll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20-minute period." C. "I'll dial 911 when I have pain and then take the nitroglycerin tablets." D. "I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting."

46.A nurse is caring for a client who is to receive a unit of packed RBCs. The nurse should prime the blood administration tubing using which of the following IV solutions? A. Lactated Ringer’s solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% in 0.45% sodium chloride

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Units 2 & 3 Practice-ATI 47.A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol injection 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

48.A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? A. "I am gaining weight." B. "I am constipated." C. "My vision seems yellow." D. "My tongue is red and beefy."

49.A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every...