n- duskly it wIll look like c. Frothy sputum-Left sided- can be blood tinged d. Jugular vein distention→ Right Rationale: ATI MS: pg. 198 ch 32 pdf Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria. Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver enlargement, 2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area where the nurse should expect the client to have referred pain. ( Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower back Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than where the pain should be felt. 2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf a. monitor the access site for drainage.- to check for sxs of infection. b. Strip the catheter tubing c. Measure the amount of the dialysate outflow d. Raise the client to high fowlers position- they must lie supine e. Position the client to her other side. 3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse plan to take? Ati video tutorials foley a. Collect urine specimen from the drainage bag 1 hr after insertion b. Raise the head of the bed to 45 degrees prior to insertion c. Secure the catheter to the client's inner thigh d. Attach the bag to the rail of the bed. –under non movable area 6. A nurse is providing teaching for a client who has age-related macular degeneration which of the following information should the nurse include in the teaching a. A possible cause of this problem is long-term lack of dietary protein b. You probably have a Detachment of your retina -vision is like having curtains over eyes c. You probably have noticed a decline in your central vision d. The doctor can perform surgery to correct the start paying the folds in your retina Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure , happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female, HTN, diet lacking carotene. 7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report? P . 357 ch 55 pdf Med surg a. Platelets 70,000/mm3- risk of bleed normal range is 150,000 - 300,00- ABCS is compromised automatically . b. Distended abdomen- expected c. Alkaline phosphatase 125 units/L -norm normal is 30 -120 D. Clay colored stools- bile not on your shit 8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of which of the following adverse effects? Old med surge docs we used a. Hyperglycemia b. Diarrhea c. Constipation d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take on higher loads, you must taper it down to avoid hypoglycemia with lower concentrations of TPN Abruptly discontinuing TPN will cause rebound hypoglycemia 9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse plan to take? P . 250 chapter 40 pdf p . 678 lewis a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older adults b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion- you get vital signs at the initial first 15 to 30 minutes of the transfusion. c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 . d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249 10. TOXIC SHOCK SYNDROME- same 11. A nurse is providing discharge teaching to an older adult client who had an exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler. WHich of the following instructions should the nurse include? ( C) p . 132 ch 22 a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat inflammation. b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters. c. Obtain a yearly influenza immunization. - reduce risk of infection. d. Assist use of pursed-lip breathing.- this is also one of the interventions the nurse does but the question ask about fluticasone. It is a steroid, and we all know steroids decresaes inflammation but also depress our immunue system. So getting a flu shot is priority. 12. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction b. “Clean the incision daily with hydrogen peroxide.”- soap and water c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip greater than 90 degrees. NO crossing legs , no turing on operative side. d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least 13. Missing 14. A nurse is caring for a client who is postoperative following a femur fracture. Which of the following findings should the nurse report to the provider immediately? a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71 b. The client has a temperature of 38.1 C (100.5F) c. The clients incision is red and warm d. The client reports incision pain 15. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? P . 290 ch 46 pdf a. Place the client in a protective environment b. Obtain a stool specimen with gloves→ CONTACT ISO c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub. 16. A nurse is setting up a sterile field before performing a dressing change on client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (select all the apply) a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder is always non sterile so its ok to touch it . b. Select a work surface at the nurses waist level- body mchiancis . c. Apply sterile gloves before opening the pack- sterile package must be opened first before donning sterile gloves d. Open the first flap of the sterile package toward the nurse's body- must be AWAY first , then sides , then TOWARDS the nurse . e. Place a surgical pack with a sterile drape on the work surface. 17. A nurse is caring for a client who has acute appendicitis. Which of the findings is the priority to the provider? Ch 23 p . 143 PEDIATRICS pdf also p 944 lewis a. Nausea- has not burst b. Flank pain - normal c. Fever - has not burst d. Rigid abdomen - muscles contract because it exploded- can lead to rupture and infection also HR ELEVATED, shallow and rapid respirations, pulse is weak. . 18. A nurse is caring for a client who is receiving radiation. The client reports nauseas since the therapy was initiated. Which of the following considerations should the nurse include when planning the clients meals? P . 583 ch 91 also ch 16 p 269 of the lewis book a. Offer frequent, high-carbohydrate meals- several small meals a day is preffered. b. Offer highly seasoned foods- you want COLD , dry , foods. Cooking stimulates odors that lead to nausea. c. Offer a snack prior to radiation therapy- several small meals a day is recommended. d. Offer hot beverages with meals- hot foods can stimulate nausea. Beverage with meals leads to nausea. 19. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement? (D) page 208-209 not sure which answer Empty water from the ventilator tubing daily. ( -INFECTION CONTROL: water that collects in the ventilator tubing can create a breeding ground for bacteria which may lead to VAP. Suction the client’s airway every 4 hr.(Suction every 2 hr and as needed. p.157) Maintain the client in supine position. (should reposition pt to help with secretions) Perform oral care every 2 hr.( you do oral care but not every 2hrs ) 20. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? ( C) a. Palmar erythema b. Spider angiomas c. Mental confusion (RM 10 Ch.55 p.359 pdf - too much bilirubin in the blood went to the brain and now caused mental encephalopathy) d. Yellow Sclera 21. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following assessment findings should indicate effectiveness of the medication a. Bowel sounds present in 4 quadrants on auscultation b. Alert and oriented to time place and person c. Lung sounds clear - it is Bumex d. Apical pulse 80 Rationale: MS RM 10 Ch.32 p.198-9 23. A nurse is caring for a client who has hypertension and has a new prescription for lisinopril. The nurse should consult with the provider about which of the following medication in the client's medication administration record? a. Potassium chloride ** found on medscape b. evothyroxine c. Acetaminophen d. Metformin Rationale: Pharm RM 7.0 Ch.20 p.151; Hyperkalemia is a complication for Lisinopril; avoid any salt substitutes containing K . 24. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan or care? a. Avoid use of anticoagulants - use it b. Place pillow under client knees - stasis danger c. Discourage leg exercises while in bed - you need it d. Apply compression stocking in lower extremities Rationale: It’s common post-op, also, resume regular activity after 4-6 wks. 25. What interferes with warfarin therapy a. Potatoes (Potassium) Oranges (Vit C) b. Bananas (Potassium) c. Cauliflower - Huge Vitamin K remember veggies Rationale: Avoid any interaction with Vitamin K when on anticoagulant therapy, and dark, leafy veggies (or just any veggies) are THE source for it. 26. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the following assessment findings indicates the nurse that the medication is effective? P , 144 ch 19 pharm pdf a. Elevation in BP b. Adventitious breath sounds c. Weight loss of 1.8 kg (4lb) in the past 24 hr d. Respiratory rate of 24/min 27. A nurse is caring for a client who has Cushing’s disease. Which of the following findings should the nurse expect? Ch 80 page 518 a. Weight loss b. Hyponatremia- increased c. Hyperglycemia d. Hypercalcemia- DECREASED ERRYTHANG is UP except K /Ca , both HYPO 28. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? (MS RM 10.0 Ch.40 p.250: chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom) a. Back pain b. Bradycardia- should be tachycardia c. Hypertension- hypotension it will cause. d. Chills 29. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? a. 75 mL of greenish yellow drainage (Purulent) b. 100 mL of red drainage (Sanguineous/fresh bleeding) c. 200 mL of brown drainage (Purulent) d. 150 mL of serosanguineous drainage 30. A nurse is performing an admission assessment on a client who has severe chronic kidney disease. Which of the following findings should the nurse expect? MS RM 10.0 Ch.59 p.382 pdf a. Lethargy b. Potassium 4.0 mEq/L c. Hypotension- HTN due to fluid overload d. Serum creatinine 0.9 mg/dL- should be increased . Rationale: Expected findings include nausea, fatigue, lethargy, involuntary movement of legs, depression, and intractable hiccups. In most cases of chronic CKD, findings are r/t fluid overload, including both HTN and orthostatic hypotension. 31. Missing 32. A nurse is teaching a client who has hypothyroidism. Which of the following information should the nurse include in the teaching? (select all the apply) pg. 886 med srg a. You will take medication for this condition for several months b. You will need to eat a high-fiber diet to prevent complications of this condition c. You might notice that you perspire more with this condition d. We will perform laboratory tests to monitor the effect of your medication e. This condition can cause you to gain weight. 33. A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? P 113 ms ati pdf a. Empty water from the client’s ventilator tubing b. Evaluate the client for a cuff leak - check this first for cause of low pressure c. Suction the client’s airway d. Increase the client’s ventilator flow rate. 34. A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon? a. INR of 1.6 (Normal 1.0-2.0) b. Platelets 95,000/mm3 (low 150,000-350,000) c. Hct 42% (Normal 42%-52% men; 37%-47% women) d. WBC 8,000/mm3 (Normal 5,000-10,000/mm3) Rationale: MS RM 10.0 Ch.39 p.245; Normal labs 35. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the following findings should the nurse identify as an indication that the medication is effective? a. Increased potassium level b. Decreased blood pressure ?? ** c. Increased heart rate ( pg 365 md srg valsartan is a afterload reducing agent, angiotensin receptor blocker ) d. Decreased urinary output 36. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the following positions should the nurse instruct the client to maintain after the procedure??? P. 882 lewis medsurg a. Prone b. Supine c. Right lateral - with minimum 2 hours, with patient bed flat. d. Left lateral Rationale: ATI Capstone question; “Following a liver biopsy, the nurse should instruct the client to lie on the affected side for hemostasis to occur. The liver sits just under the rib cage on the right side of the abdomen.” 37. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? MS RM 10.0 Ch.92 p.614 a. “I will have to wait 2 months before additional saline can be added to my breast expander” (tissue expanders have ports for additional injection of saline for gradual expansion & is encouraged) b. “I will perform strength building arm exercises using a 15 pound weight” (Squeeze a rubber ball, elbow flexion/extension, hand-wall climbing to promote full ROM and prevent lymphedema) c. “I should expect less than 25 ml of secretions per day in the drainage devices” d. “I will keep my left arm flexed at the elbow as much as possible” (Elbow flexion AND extension) 38. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include? Ch 82 page 532 a. “Wash your feet twice per day with antibacterial soap and hot water” b. “Wear loose fitting slippers around the house” c. “Wear cotton rather than nylon sock” d. “Use a heating pad to keep your feet warm at night” 39. A nurse is caring for a client following the placement of a transverse colostomy. Which of the following findings indicates a possible complication? a. Client reports pain of 6 on scale from 0 to 10 b. Heart rate 110/min c. Bowel sounds hypoactive d. Stoma appears dry p. 602.. Stoma should be pink , moist , ischemia should be reported to the provider. 40. A nurse is counseling a client who has a family history of hypertension about reducing high risk for high blood pressure. Which of the following strategies should the nurse recommend? P .161 a. Engage is isometric exercises for 15 min daily b. Maintain a body mass index between 31 and 34 c. Lower total cholesterol level 200 mg/dL d. Increase dietary potassium intake 41. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address? P . 645 a. Piloerection of the skin b. Vomiting upon arousal c. Decreased body temperature- increases risk for wound infection, cardiac dysrhymias, altered absorpton of medication. d. Indistinct, rambling speech 42. A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include? a. Change the dressing four times per day b. Use sterile gloves when performing the dressing change ??? ( they dont have to use sterile they can use clean gloves ) c. Clean from the incision to the surrounding skin d. Apply tincture of benzoin prior to removing the dressing 43. A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia. Which of the following clinical manifestations should the nurse instruct the client to monitor for and report? a. Pallor of the extremities b. Taste of metal in the mouth c. Halo of light around objects d. Ringing in the ears- ototoxic is vanco p 359 pharm ati pdf 44. A nurse is caring for a client who has pancreatitis and has been receiving total parenteral nutrition. Which of the following laboratory tests should the nurse monitor for overall nutritional status? a. Prealbumin b. C reactive protein c. Creatinine d. Lipase 45. A charge nurse is called to a client’s room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take? Page 650 MS ATI PDF 10.0 im stuck with c and d . its says with cover the wound with a sterile saline soaked towel or dressing a. Attempt to reinsert the protruding viscera- DO NOT ATTEMPT TO REINSERT ORGANS b. Obtain bottles of warm, sterile 0.9% sodium chloride solution wouldn’t you want to get sterile solution for the dressing cover to put on the wound? c. Place the client in left lateral recumbent position- low fowlers hips knees bent (ati book p1111 “place in supine position with hips and knees bent”) which is lithotomy position, not recumbent d. Apply a firm pressure dressing across the client’s abdomen - in practice A/B. confirmed (p1111 ati book “cover wound with sterile dressing”--doesn’t mean apply firm pressure) 46. A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis? Pg 283 ati a. A client who is receiving continuous gastric suctioning b. A client who has aspiration pneumonia c. A client who is experiencing an opioid overdose- respiratory acidosis. d. A client who has uncontrolled diabetes mellitus 47. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity? a. Calcium b. Potassium c. Magnesium d. Phosphatase Rationale: Digoxin level and Potassium levels are inversely correlated. So if you have less K your digoxin levels shots up leading to digoxin toxicity and if your K is high digoxin level is low. 48. A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider? a. Erythema (redness can be indicative of infection) b. Ecchymotic skin c. Drainage (expected for 3-4 days?) d. Edema ??? 49. A nurse is completing an admission assessment for a client. The nurse should expect the provider to prescribe which of the following medications for the client? EXHIBIT VITAL SIGNS: Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg) a. Atorvastatin b. Allopurinol c. Metoprolol d. levothyroxine 50. A nurse is assessing a client who is near the end of life following a head injury. The client has alternating periods of rapid breathing and apnea. The nurse should document this finding as which of the following respiratory patterns? page 75 ch 14 a. Biot’s respirations- quick shallow respirations followed by apnea. b. Hypoventilatory respirations- opoid overdose c. Kussmaul respirations- hyperglycemia d. Cheyne-Stokes respirations- occurs during INCREASED INTRACRANIAL PRESSURE 51. A nurse is administering a unit of packed RBCs to a client and notes that there are several small clots floating in the IV bag. Which of the following actions should the nurse take? a. Inject 5,000 units of heparin into the unit of packed RBCs b. Place the unit of packed RBCs in a warming unit for 5 min c. Return the unit of packed RBCs to the blood bank- return that shit d. Dilute the unit of packed RBCs using 50 mL of lactated Ringer’s 52. A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include? a. “Eat a light meal 1 hour before bedtime”- avoid eating before bedtime b. “Lie down for 30 minutes after each meal”- CANNOT BE SUPINE c. “Increase your caloric intake by 250 calories per day” d. “Sleep with the head of your bed elevated 6 inches”- Rationale: so your acid doesn’t hit your throat when you sleep pg 309 57. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a. Generalized abdominal pain b. Cloudy effluent c. Fever d. Increased heart rate Rationale: Peritonitis Assessment Findings : Rigid, board-like abdomen(hallmark), abd distention, N&V, Rebound tenderness, tachycardia, FEVER. 58. A nurse is caring for a client who is receiving enteral nutrition. Which of the following interventions by the nurse will prevent aspiration? a. Check the gastric pH following bolus feedings ( for verifying placement) b. Place the client in supine position before initiating feedings (No; 30 degree) c. Instruct the client to perform the Valsalva maneuver after feedings (no) d. Measure residual volume prior to bolus feedings Rationale: Nursing measures to prevent aspiration include verifying tube placement, checking gastric residuals, assessing bowel function to confirm peristalsis, and elevating the head of the patient’sbed to 30 degrees or more during feeding and at least 1 hour after feeding. Monitor fluid and electrolyte balance carefully; additional water may be prescribed based on the patient’s fluid status. Providing mouth care is particularly important for patients receiving enteral feedings, as is addressing the psychosocial aspects of care. 62. Client has a pressure ulcer. Which indicates wound healing? a. Light yellow exudate (Seropurulent) b. Wound tissue firm to palpation (firm, not healing yet) stage 1. c. Dry brown eschar (dead skin?) d. Dark red granulation tissue p . 330 fundamentals Ratonale: Red: Healthy regeneration of tissue Yellow: Presence of purulent drainage and slough Black: Presence of eschar that hinders healing and requires removal 63. STEPS to use of a peak flow meter a. “Stand upright” 1 b. “Seal your lips around the mouth piece”3 c. “Fill your lungs with a deep breath”2 d. “Exhale forcefully and quickly”4 e. “Record the highest of three consecutive readings”5 Rationale: A,C,B,D,E 1. Stand up or sit up straight. 2. Make sure the indicator is at the bottom of the meter (zero). 3. Take a deep breath in, filling the lungs completely. 4. Place the mouthpiece in your mouth; lightly bite with your teeth and close your lips on it. Be sure your tongue is away from the mouthpiece. 5. Blast the air out as hard and as fast as possible in a single blow. 6. Remove the meter from your mouth. 7. Record the number that appears on the meter and then repeat steps one through seven two times. 8. Record the highest of the three readings in an asthma diary. This reading is your peak expiratory flow (PEF). 67. Client, who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a. Palpate the dorsalis pedis pulse. b. Maintain the affected extremity in a dependent position (ELEVATE) c. Wrap sterile gauze on the shart point of the pins (NOPE 8-12HRS) d. Adjust the clamps on the fixator flame (NEVER, MD DOES THIS) Rationale: Elevate extremity, Monitor neurovascular status and skin integrity, Assess body image, Perform pin care every 8 to 12 hr, Monitor site for drainage, color, odor, redness, Observe for manifestations of fat and pulmonary embolism, Provide antiembolism stockings and sequential compression device to prevent deep-vein thrombosis (DVT). 68.) A nurse is preparing an in-service presentation about the use of automated external defibrillators (AEDs). Which of the following instructions should the nurse include in the teaching? a. “Perform CPR while the AED is analyzing”-cannot due b/c analysis will be wrong b. “Position the client on a flat surface” c. “Set the AED to 80 joules” (should be 200 joules) d. “Use an AED for a client who has A-fib” (AED is for V-fib & V-tach) Rationale: Process of Elimination and Think. 69. Serum sodium level of 120 mEq/L. Which of the followings findings should the nurse expect? P . 271 a. Hyperreflexia - Decreased DTRs b. Decreased bowel sounds - increased motility , ab cramping, nausea. c. Confusion** d. Increased central venous pressure- Rationale: MANIFESTATION OF HYPONATREMIA :Weakness, Lethargy, CONFUSION, Seizures, Headache, Anorexia, N&V, Muscle Cramps, twitching, Hypotention, Tachycardia, Wt gain and Edema. 271 MS pdf also, headache, lethargy, muslce wekaness to the point of respiratory cimpromise, decreased DTRs, seizures, light headed , dizzy, 70. Pt. taking isoniazid and rifampin, which understands? a. “I will be finished with this medication regimen in 3 months” -9 months b. “I should check the whites of my eyes while taking these medications” - very hepatotoxic c. “I should take my mediation with an antacid if it upsets my stomach” (Taking antacid would decrease effectiveness of the medication so it is not advised or SHOULD not take it during treatment) d. “I will no longer be infectious after two consecutive negative sputum specimens” (THREE) Rationale: Assess for toxicity because both medication are very toxic you are at risk for hepatotoxicity. Other choices are WRONG, Eliminate it. 72. The use of incentive spirometer. a. Position the mouthpiece 2.5cm (1 in) from the mouth (put in ur mouth) b. Place hands on the upper abdomen during inhalation (no hold spirometer) c. Hold breaths about 3-5 secs before exhaling (repeat) d. Exhale slowly through purse lips (With Purse lip breating not Spirometer) Rationale: The client who is using the spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the client exhales, the needle of the spirometer rises. This promotes lung expansion. (per ATI med surg) 1. Sit on the edge of your bed if possible, or sit up as far as you can in bed. 2. Hold the incentive spirometer in an upright position. 3. Place the mouthpiece in your mouth and seal your lips tightly around it. 4. Breathe in slowly and as deeply as possible. Notice the yellow piston rising toward the top of the column. The yellow indicator should reach the blue outlined area. 5. Hold your breath as long as possible. Then exhale slowly and allow the piston to fall to the bottom of the column. 6. Rest for a few seconds and repeat steps one to five at least 10 times every hour. 7. Position the yellow indicator on the left side of the spirometer to show your best effort. Use the indicator as a goal to work toward during each slow deep breath. 8. After each set of 10 deep breaths, cough to be sure your lungs are clear. If you have an incision, support your incision when coughing by placing a pillow firmly against it. 9. Once you are able to get out of bed safely, take frequent walks and practice the cough. 73. Pt. who is in septic shock. Which lab findings indicate the patient is developing “multiple organ dysfunction syndrome”? a. Arterial hypoxemia (low / no O2 manifestation of MODS) b. Decreased liver enzymes- Increased c. Decreased BUN - Increased d. Hypoglycemia - body response increase to save body Rationale: MODS can develop from severe hypotension and reperfusion of ischemic cells, causing further tissue injury. Inadequate tissue perfusion can cause organ failure in the lungs (adult respiratory distress syndrome), kidneys, heart (decreased coronary artery perfusion, decreased cardiac contractility), and the gastrointestinal tract (necrosis).. So MODS happends when no O2 is being delviered 75. A nurse is reviewing a client’s laboratory values and notes a potassium level of 2.8 mEq/L. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds (Hypoactive) b. Increased blood pressure (Hypotension) c. Irregular pulse d. Exaggerated reflexes (CM of Hyperkalemia) Rationale: Manifestion of Hypokalemia: IRREGULAR PULSE, Muscle weakness and cramping, Fatigue, Nausea, Vomiting, Irritability, Confusion, Decrease Bowel sound, Paresthesia, Dysrhythmias, Flat/ inverted T wave, 76. A nurse is caring for a client who is admitted to the medical-surgical unit with a seizure disorder. Which of the following interventions should the nurse include in the plan of care? a. Teach assistive personnel how to apply restraints -- do not attempt to restrain the client b. Keep the side rails in a down position → a) side- rails up with padding to prevent injury c. Keep a padded tongue blade at the client’s bedside → do not use padded tongue blades. d. Maintain peripheral IV access. RATIONALE: ATI MS ATI MS 36 Priority: Maintain peripheral IV access in case of emergency may administer diazepam, or lorazepam IVP followed by IV phenytoin or fosphenytoin. side- rails up with padding to prevent injury 77. A nurse is collecting a medical history from an older adult client who has hypertension and new prescription of nadolol. Which of the following findings should the nurse report to the provider? a. cataracts b. GERD c. Asthma d. Hypothyroidism RATIONALE: ATI PHARM 263 Avoid in clients who have asthma. Bronchoconstriction effect. And if you guys could remember about the JNC8 per Tiamson. 78. A nurse is preparing a client for a Lumbar puncture. Which of the following images indicates the position the nurse should assess the client into for this procedure? (Here are some of the choices) But the correct one is FETAL POSITION. FETAL POSITION or SITTING FORWARD ON THE TABLE. (ATI MS 21) 78. A nurse is caring for a client who has a diabetes mellitus. The client’s ABG are ph 7.14, PaO2 90 mmHg, PaCO2 35 mmHg, and HCO3 4 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis RATIONALE: ATI MS pH 7.35- 7.45 7.14 Acidosis CO2 35-45 35 compensating HCO3 22-26 4 metabolic 80. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? a. Increase Phosphorus b. Increase Potassium c. Decrease protein intake d. Decreased carbohydrate intake. à Increased carbs is what you want RATIONALE: ATI MS Nephrotic syndrome kidney disorder characterized by massive proteinuria, hypoalbuminemia & edema AVOID excess protein, high amounts of FAT, & minimize Na → more fluid retention 81. A nurse is planning care for a client who has new diagnosis of acute pancreatitis. Which of the ff interventions should the nurse include in the plan of care? a. Administer antihypertensive meds b. Maintain the client on NPO status c. Place client in supine position d. Monitor the client for hypercalcemia RATIONALE: ATI MS 348 NPO: no food until pain-free 82. A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? a. Altered level of consciousness b. Pupillary constriction c. Decorticate posturing d. Cheyne-stokes respirations RATIONALE: ATI MS 19 All manifestation of ICP. But FIRST sign of deteriorating neurological status is ALOC → pupillary constriction → cheyne posturing → Cheyne-stokes respirations. You may use Glasgow coma scale to assess neurological status. 83. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a.) Captopril → Ace Inhibitor b.) Ibuprofen → NSAIDS c.) Digoxin → antidysrhythmic d.) Phenytoin → anticonvulsant RATIONALE: ATI MS 84. A nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse’s priority? a. Obtain a WBC count with differential b. Obtain a history to determine recent injuries. c. Obtain a blood specimen of culture and sensitivity testing d. Obtain a broad-spectrum antibiotic for rapid administration. RATIONALE: ATI MS 85. A nurse is assessing a client following a kidney biopsy. Which of the following findings should the nurse identify as an indication that the client is experiencing internal bleeding? a. Bradycardia→ Tachycardia, Hemorrhaging b. Polyuria → Urgency, complications c. Flank Pain d. Increase Blood Pressure→ Hypotension, Hemorrhaging RATIONALE: ATI MS 144 Monitor for internal bleeding (measure abdominal girth and abdominal or flank pain) at least Q8hr. TBC 86. A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 ml in the past 12 hr. which of the following medications should the nurse expect to administer to the client? a. Dopamine b. Desmopressin acetate c. Furosemide d. Spironolactone RATIONALE: ATI Pharm 532 ATI MS 499 Diabetes insipidus has deficiency of ADH. Manifestation of 3 P’s: polyuria, polyphagia, and polydipsia. Administer ADH (desmopressin) to stop polyuria and prevent dehydration. 87. A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? a. Sneezing b. Presence of a sharp spike prior to the QRS complex on the ECG c. Hiccups d. Presence of intrinsic P waves following a QRS complex on the ECG RATIONALE: ATI MS 177 Assess for hiccups, which can indicate that the generator is pacing the diaphragm. 88. A nurse is caring for a client receiving TPN who weighs 160Lb. If the RDA of protein is 0.8g/kg of body weight. How many g of protein should the client receive? 160 lbs/2.2 72.72 kg 0.8 g x 72.72 kg 58g 89. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? (D) a. Dilated appearance of the graft b. Normotensive blood pressure c. Absence of a bruit d. Palpable thrill RATIONALE: ATI MS Adequate circulation of the graft has manifestation of palpable thrill arterial and venous, indicates good blood flow and patency. 90. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following indicates effective of the teaching? a. I should expect my lesions to resolve in 6 weeks b. I should expect to take my medication for 3 weeks c. I should use natural skin condoms during sex. → Avoid SEX d. I should apply antibiotic ointment to lesions. → Acyclovir – antiviral medication RATIONALE: ATI MS 91. A nurse is caring for a client who has a history of chemotherapy-included nauseas and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? a. Ondansetron b. Sertraline c. Diphenhydramine d. Methylprednisolone RATIONALE: ATI MS 581 Serotonin blockers, such as ondansetron, have been found to be effective and are often administered with corticosteroids, phenothiazines, and antihistamines 92. A nurse is preparing to administer daily medications to a client who is undergoing procedure at 1000 that req IV contrast dye. Which of the following routine meds to give at 0800 should the nurse withhold? a. Metoprolol b. Metformin c. Fluticasone d. Valproic Acid RATIONALE: ATI MS 364 Withhold METFORMIN for 24 hr. before the procedure (risk for lactic acidosis from contrast dye with iodine). 93. A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take? a. Confirm the correct position of the line by obtaining a blood sample. - Xray b. Instruct the client to cough as the catheter is inserted. - Cough may shift vessels danger c. Place the head of the client’s bed lower than the foot. d. Cleanse the site with a hydrogen peroxide solution.- chlorhexidine RATIONALE: ATI MS For central line insertion, tubing change, and line removal, place the client in the Trendelenburg’s position if not contraindicated or in the supine position, and instruct the client to perform the Valsalva maneuver to increase pressure in the central veins when the IV system is open. 94. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? a. Hypotension → HYPERTENSION Weight gain→ due to the build of peripheral edema Bradycardia → TACHYCARDIA Loss of skin turgor → this happened when you’re dehydrated. RATIONALE: ATI MS 267 Hypervolemia, as there is excess fluid in the extracellular space. Other signs: peripheral edema due to an excess of fluids within the body and lungs, resulting in weight gain, distended neck veins, and increased urine output. 95. A nurse is reviewing discharge teaching with a client with a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? A. “I know the medication increases my risk for blood clots.” B. “I should avoid taking ibuprofen while taking this medication.” C. “I will increase green leafy vegetables in my diet.” D. “I will return in 1 month to have my blood tested.” Rationale page 143: Warfarin is an anticoagulant. Use to prevent blood clots from getting larger or additional clots from forming. Needs weekly blood draws, not monthly. Do not increase intake in foods high in vitamin K (green leafy vegetables). Vitamin K reduces the anticoagulant effects of warfarin. Aspirin and ibuprofen should not be used as painkillers when taking on warfarin because it increases risk for bleeding and bruising. 96. A nurse is caring for a client who has glaucoma. Which of the following findings should the nurse expect? a. The client reports loss of peripheral vision. b. The client’s eyes are watery c. The client’s pupils are constricted. d. The client reports dark floaters in the affected eye. Rationale: page 65. Glaucoma us a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secretion increases intraocular pressure (IOP) and can cause atrophic changes of the optic nerve and visual defects. Expected reference range for IOP is 10-21 mm/Hg. ● Two types of glaucoma: ○ Open-angle glaucoma: MORE COMMON. Refers to the angle between the iris and the sclera. The aqueous humor outflow is decreased due to blockages in the eye’s drainage system, causing a rise in IOP. ■ Expected findings: HA, mild eye pain, LOSS OF PERIPHERAL VISION, decreased accommodation, halos seen around lights, elevated IOP ○ Angle-closure glaucoma: IOP rises suddenly. The angle between the iris and the sclera closes suddenly which causes the IOP to increase. NEEDS IMMEDIATE TREATMENT. ■ Expected findings: radif onset of elevated IOP, decreased or blurred vision, colored halos seen around lights, pupils nonreactive to light, severe pain and nausea, and photophobia. 97. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care? a. Remind the client to use a cane on his left side while ambulating. b. Provide the client with a short-handled reacher. c. Position the bedside table on the client’s left side. d. Place a plate guard on the client’s meal tray. Rationale: place beside table near the patient’s bed on the unaffected side. 99. A nurse is planning to flush an implanted port for a client who is receiving chemotherapy. Which of the following supplies should the nurse plan to use? a. A short peripheral catheter b. A winged infusion needle c. A non-coring needle d. A large-bore needle Rationale: page 166. Access with a noncoring (Huber) needle 100. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? “I can have mayonnaise on my sandwiches.” 105 mg “I can drink vegetable juice with a meal.” 141 mg “I can season my foods with garlic and onion salts.” “I can have a frozen fruit juice bar for dessert.” 4 mg 101. A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment? A. Run tongue blade on the outside of the client’s sole and note any flaring of the toes. B. Tap the facial nerve and note any facial twitching - chvostek signs (low Ca) C. Strike the clients patellar tendon with a percussion hammer and note any increase in response D. Gently elevate the client's head and note any nuchal rigidity. Rationale: page 31 Med Surg 2016 → PRIORITY TWO (*did this one*) 1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.0 Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. Since it is 12 hours postoperative there might be absent bowel sounds (normal), but after 24 hours and if there are absent bowel sounds after drinking and eating should be a concern. 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonate Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and to stop patient on urinating. 3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood c. Urine for white blood cells d. Serum calcium Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abdominal pain). 4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansertron. Rationale: No idea what the Exhibit is all about; won’t be able to answer it. 5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanyl b. Intramuscular meperidine c. Oral acetaminophen d. Intravenous dexamethasone Rationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. A short-acting pain medication is administered for breakthrough pain. 6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? a. PR interval b. QRS duration c. T wave d. ST segment Rationale: ST elevation indicates MI. ST depression indicates ischemia 7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? a. Pat the skin on the radiation site to dry it b. Apply OTC moisturizer to the radiation site c. Cover the radiation site loosely with a gauze wrap before dressing d. Use a soft washcloth to clean the area around the radiation site Rationale: pg. 584. Dry the area thoroughly using patting motions. 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a. Diphenhydramine b. Acetaminophen c. Pantoprazole d. Furosemide Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress. 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? a. Lungs clear b. Apical pulse 82/min c. Hyperactive bowel sounds d. Blood pressure 90/50 mm Hg Rationale: pg. 278 Confirmed on answer sheet 10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Compensated respiratory alkalosis d. Uncompensated respiratory acidosis Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis. 11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours? A. Decreased BUN (elevated due to fluid loss) B. Hypoglycemia (High due to stress) C. Hypoalbuminemia (Low due to fluid loss) D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase) Rationale: Pg. 481 ATI. Total protein and albumin- low due to fluid loss. 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate carbs page 317, chapter 49 Peptic ulcer disease med surge ATI PDF 10.0) b. Provide the client with four full meals a day (Small frequent meals) c. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr. prior and following a meal) d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines) Rationale: ATI pg. 318 Dumping syndromes is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. 12. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? a. Born with a high weight b. Chronic infections of the middle ear c. Use a loop diuretic diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin leads to ototoxic medication d. Perforation of the ear drum e. Frequent exposure to low volume noise Rationale: Pedia ATI pg. 77 Exposure to loud environmental sounds. Hearing defects can be caused by a variety of conditions, including anatomic malformation, maternal ingestion of toxic substances during pregnancy, perinatal asphyxia, perinatal infection, chronic ear infection, and ototoxic medications. 13. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Administer the plasma immediately after thawing b. Transfuse the plasma over 4 hour (Can be in 2 to 4 hours) c. Hold the transfusion if the client is actively bleeding (YOU HAVE TO GIVE IT. That’s the whole point! The patient is losing blood so you have to replace it. We give fresh frozen plasma because he or she may have clotting deficiencies) d. Administer the transfusion through a 24 gauge saline lock (Has to be a 18 or 20 gauge) Rationale: Saunders pg. 164 Fresh-frozen plasma 1. Fresh-frozen plasma may be used to provide clotting factors or volume expansion; it contains no platelets. 2. Fresh-frozen plasma is infused within 2 hours of thawing, while clotting factors are still viable, and is infused over a period of 15 to 30 minutes. 3. Rh compatibility and ABO compatibility are required for the transfusion of plasma products. 4. Evaluation of an effective response is assessed by monitoring coagulation studies, particularly the prothrombin time and the partial thromboplastin time, and resolution of hypovolemia. 14. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? a. Hyponatremia b. Hyperchloremia c. Hypermagnesemia d. Hypocalcemia Rationale: (ch 44 page 277 MS ATI PDF 10.0) Positive s/s of CHvostek’s or Trousseau sign indicates HYPOCALCEMIA. 15. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? a. Change the transparent dressing over the insertion site every 48 hours - transparent dressing can be up to 7 days b. Clean the insertion site with mild soap and water - when showering, must insertion site must be covered!!!!! No water can be in it. c. Measure your right arm circumference once weekly- does not say in the chapter d. Use a 10 milliliter syringe when flushing the catheter Rationale: (Chapter 27 cardiovascular diagnostics and therapeutic procedures p. 166 MS ATI PDF 10.0) Use transparent dressing to allow for visualization. Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). Shower, cover dressing site to avoid water exposure. Follow the Infusion Nurses Society (INS) practice recommendations for flushing. Use a 10 mL syringe for flushing the PICC line. Do not apply force if resistance is met. 16. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? a. RBC count of 4.7 million/mm (4.5-5.3M; 4.1-5.1) b. BUN 22-mg/ dl – (5-25 mg/dl) 10-20 c. WBC count of 16,000/ mm 3 à Elevated; phlebitis is a complication; infection is a complication that can happen 7 days after insertion, also temp increase if 1 degree can happen (5,000-10,000) d. Blood glucose of 120 mg/dl (70-110) Rationale: (P.166 MS ATI PDF 10.0) 17. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entire day b. I should increase my intake of canned salmon to three times per week (NO SODIUM) c. I will season my food with lemon pepper rather than salt (We do not want to give the dietary sodium, potassium, phosphorus, and magnesium. I don’t know what lemon pepper has, but we want to RESTRICT sodium, potassium, phosphorus and magnesium.) d. I should limit my intake of hard cheese to 3 ounces each day (NO SODIUM) Rationale: (p.382 chapter 59) Rationale: ATI MS pg. 382-control protein intake based on the client’s stage of CKD and type of dialysis. Restrict sodium intake to prevent fluid retention and hypertension Low GFR indicates CRD. 18. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? a. Administer 20 ml of 0.9 sodium chloride after each dose of medication à (you only flush with 10 ml of NS, not 20. 20 is for flushing blood) b. Flush the catheter using a 5 ml syringe à you use a 10mL syringe to flush c. Verify the placement with an x-ray prior to the initial dose (POSTPROCEDURE) d. Change the transparent membranes dressing daily (dressing can last for up to 7 days) Rationale: (PAGE 166 ch 27 MS ATI PDF 10.0 19. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? a. Do not shake your inhaler before use à shake 5-6x. b. Exhale fully before bringing the inhaler to your lips c. Depress the canister after you inhale (depress the inhaler as the patient inhales to go in the lungs). d. Use peroxide to clean the mouthpiece if your inhaler (mild soap and water) Rationale: Pharm ATI pg. 7 Review TABLE for administration of MDI. For an MDI, instruct the client to: ».Remove cap from inhaler. ».Shake inhaler five to six times. ».Hold inhaler with mouthpiece at the bottom. ».Hold inhaler with thumb near mouthpiece and index and middle fingers at top. ».Hold inhaler approximately 2 to 4 cm (1 to 2 in) away from front of mouth. ».Take a deep breath, and then exhale. ».Tilt head back slightly, and press inhaler. While pressing inhaler, begin a slow, deep breath that should last for 3 to 5 seconds to facilitate delivery to the air passages. ».Hold breath for 10 seconds to allow medication to deposit in airways. ».Take inhaler out of mouth, and slowly exhale through pursed lips. ».Resume normal breathing. 20. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? a. A client who has angina reports substernal chest pain b. A client who has pancreatitis reports pain in the left shoulder à referred pain is pain that is felt in another place that is not in the same area as where the pain should be felt. Pain radiates on a certain location of the body. c. A client who is postoperative reports incisional pain d. A client who has peritonitis reports generalized abdominal pain Rationale: ATI MS (page 30) Visceral: in internal organs such as the stomach or intestines. It can cause referred pain in other body locations separate from the stimulus. 21. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? a. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. (The patient just came from surgery so pain is normal for post op patients for first couple of hours.) b. The client’s capillary refill in the left toe is 6 seconds signs and symptoms of compartment syndrome à ABCs are compromised. (Cap refill should be below 3 seconds. This is s/s for compartment syndrome. Untreated can lead to necrosis.) c. The client has an oral temperature of 38.3 (100.9 F) (I wouldn’t pick this because i always see temp 101 as a priority from previous rationales with other atis.) d. The client has 100 ml of blood in the closed suction drained. (I believe this is normal for post-op patients.) Rationale: (p .456 MS ATI PDF 10.0 chapter 71) Assess 5 P’s: pain, paralysis, paresthesia, pallor, pulselessness 22. A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to intervene? a. Right upper quadrant pain (patient has acute pancreatitis, so it’s normal) b. Capillary blood glucose level of 164 mg/dl - glucose not significantly high c. WBC counts 13,000/mm3 (Infection is one complication of TPN administration d. Crackle in bilateral lower lobes (Priority, FVE/fluid shifts to the lungs may lead to respiratory distress/collapse/failure) life threatening than infection. May need to decrease ml/hr and assess. Rationale: (chapter 47 page 299 MS ATI PDF 10.0) (ABC’s compromised, also one of the complications of TPN is fluid imbalance aka fluid volume excess.) 23. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? a. Reverse Trendelenburg (page 232 says for hypotension patients must be flat with legs elevated to increase venous return.) b. Side Lying c. High Fowlers d. Feet elevated Rationale: Manifestations of Heart failure/Cardiogenic Shock Pg. 195. Chapter 31 MS ATI PDF 10.0) 24. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red- orange in color. Which of the following responses should the nurse make? a.) “This finding may indicate possible medication toxicity” b.) “Your provider will prescribe a different medication regimen” c.) “This is an expected adverse effect of this medication.” d.) “You will need to increase your fluid intake to resolve this problem” Rationale: pg. 137 ATI MS Expected to be orange in rifampin: urine/secretions 25. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? a.) Administer the unit through secondary IV tubing (Y-ports) b.) Verify the blood product with assistive personnel (another RN) c.) Begin an IV infusion of 0.9% sodium chloride d.) Insert another 22-gauge IV catheter (18-20 gauge is recommended. 22 is too small) Rationale: ATI Pharm pg. 355 Insert an intravenous (IV) line and infuse normal saline; maintain the infusion at a keep-vein-open rate. An 18- or 19-gauge IV needle will be needed to achieve a maximum flow rate of blood products and to prevent damage to red blood cells; if a smaller gauge needle must be used, red blood cells may be diluted with normal saline (check agency procedure). Use only 0.9% sodium chloride solution to administer with blood products; prime IV and blood tubing with this solution. Use a blood filter for most blood products and either a Y-type or straight tubing set depending on facility policy. 26. A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? a.) Check the client’s blood pressures every 8 hr. b.) Administer opioids PO c.) Assess urine output hourly ---à prevent shock and mods d.) Monitor for hypokalemia as a manifestation of acute rejection Rationale: Pg. 374 28. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? a.) Captopril –ace inhibitor b.) Ibuprofen --NSAIDS c.) Digoxinà antidysrhythmic d.) Phenytoin-seizure 30. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the following findings should the nurse expect? a.) Blanching of the hands à REYNAUD PHENOMENON b.) Hyperactive reflexes c.) Calf pain with foot dorsiflexion d.) Vitiligo on affected extremities Rationale: (P 558 at i MD pdf 10.0) Epiosodic vasospasm in the small peripheral arteries and arterioles, precipitated by exposure to cold or stress usually affects the hands or less often the feet. CREST Calcinosis- calcium deposits in the skin Raynaud phenomenon- spasm of blood vessels in response to cold or stress Esophageal dysfunction- acid reflux and decease in mortility of esophagus Scierodactyly- thickening and tightening of the skin on the fingers and hands Telangiectasias- dilation of capillaries causing red marks on surface of skin. 31. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? a. A client who has a peripherally inserted central catheter in the left arm b. A client who has left-sided Bell’s palsy c. A client who has a right upper extremity arteriovenous fistula (always use opposite arm from an AV fistula) d. A client who has right-sided weakness due to Parkinson’s disease 32. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? a. Hypertension b. Cirrhosis c. NSAIDS use d. Oral Contraceptive Use Rationale: page 141 of ATI Book 2016 33. A nurse is caring for client who has Cushing’s disease. Which of the following actions should the nurse takes first? (Click Exhibit button for additional information) a. Check the client’s medication administration record for antihypertensive medication. b. Verify the client’s understanding of sodium restriction. c. Auscultate the client’s lung sound -à due to fluid retention; action first varies on the exhibit d. Determine the need for further glucose monitoring Rationale: cushings disease:increase in cortisol. Hyperglycemia, obesity, striae, moon round face, osteoporosis, buffalo hump, gynecomastia, bruise easily, fluid retention, hypertension 34. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? a. Proteinuria b. Flank pain c. Hyperalbuminemia d. Hypotension Rationale: Lewis book page 1075. Clinical manifestation of N.S.: peripheral edema, massive proteinuria, HTN, hyperlipidemia, and hypoalbuminemia. 35. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? a. Oliguria (Left) b. S3/S4 galloping heart sounds (Left) c. Poor skin turgor d. Pitting edema Rationale: Page 198 Chapter 32 of ATI Book. Additional source pg. 363 36. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? a. Notify the provider when tidaling ceases. (Yes notify) b. Assisting the client out of bed three times daily. c. Vigorously strip the chest tube twice daily. (Vigorously and BID) d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. (Don’t need to clarify) Rational