ATI RN Custom NURSING 221 Exam 3
Total Questions : 53
Showing 25 questions, Sign in for moreA charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?
Explanation
Choice A rationale:
Alcohol-based hand rubs are not recommended before administering eye drops as they can cause eye irritation.
Choice B rationale:
Chlorhexidine is recommended for hand hygiene when caring for immunosuppressed clients as it has broad-spectrum antimicrobial activity.
Choice C rationale:
Alcohol-based hand rubs are not effective against Clostridium difficile. Soap and water should be used instead.
Choice D rationale:
Artificial nails can harbor pathogens and are not recommended in healthcare settings.
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
Explanation
Choice A rationale:
Behavioral indicators are the most reliable way to assess pain in a client with expressive aphasia as they may not be able to verbally communicate their pain.
Choice B rationale:
Scheduled treatments and client illness do not directly indicate the client’s pain level.
Choice C rationale:
Pulse and blood pressure findings can be influenced by many factors and are not the most reliable indicators of pain.
Choice D rationale:
A self-report pain rating scale would not be effective for a client with expressive aphasia as they may have difficulty understanding and using the scale.
A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm² with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results?
Explanation
Choice A rationale:
An increased WBC count with increased bands (immature neutrophils) indicates an acute infectious process. Normal range for WBC is 4,500-11,000/mm².
Choice B rationale:
A resolving inflammatory process would typically show a decreasing WBC count.
Choice C rationale:
An allergic reaction would typically show an increase in eosinophils, not neutrophils.
Choice D rationale:
Neutropenia is a decrease in neutrophils, not an increase.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms.
Which of the following is the priority action the nurse should take?
Explanation
Choice A rationale:
Inspecting the mouth for signs of inhalation injuries is the priority action. Inhalation injuries can lead to airway obstruction and respiratory failure, which are life-threatening conditions.
Choice B rationale:
Administering intravenous pain medication is important, but it is not the priority. Pain management is necessary but secondary to life-threatening conditions.
Choice C rationale:
Inserting an indwelling urinary catheter is done to monitor renal function and fluid balance, but it is not the priority action in this case.
Choice D rationale:
Drawing blood for a complete blood cell (CBC) count is done to assess the client’s overall health status, but it is not the priority action.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
Explanation
Choice A rationale:
Checking the catheter tubing for kinks or twisting helps to maintain a patent urinary drainage system, preventing urinary stasis that can lead to infection.
Choice B rationale:
Irrigating the catheter once each shift is not recommended as it can introduce bacteria into the bladder.
Choice C rationale:
Cleaning the perineal area with an antiseptic solution daily can disrupt the normal flora and cause irritation, potentially leading to infection.
Choice D rationale:
Replacing the catheter every 3 days is not recommended as it can increase the risk of urinary tract infection.
A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?
Explanation
Choice A rationale:
Putting beverages in large containers can give the appearance of drinking a lot, but it does not help in managing fluid restrictions.
Choice B rationale:
Consuming most of the fluid during the evening can lead to nocturia and disrupt sleep.
Choice C rationale:
Making a list of favorite beverages does not necessarily help in managing fluid restrictions.
Choice D rationale:
Not adding ice cream to the amount of fluid intake is correct as ice cream is considered a fluid and should be counted in the total fluid intake.
A nurse enters a client's room and finds the client on the floor having a seizure.
Which of the following actions should the nurse take?
Explanation
Choice A rationale:
Placing the client back in bed during a seizure could lead to injury.
Choice B rationale:
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
Choice D rationale:
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
Explanation
Choice A rationale:
Sensitivity to light is common after cataract surgery and does not need to be reported.
Choice B rationale:
Severe pain could indicate complications such as increased intraocular pressure or infection.
Choice C rationale:
Itching is common after surgery due to healing and does not need to be reported.
Choice D rationale:
Difficulty with vision is expected due to the eye patch, but fear of falling should be addressed through safety measures, not necessarily reported to the provider.
A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse's priority?
Explanation
Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.
A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia.
Which of the following actions should the nurse take?
Explanation
Choice A rationale:
Obtaining a sputum culture helps identify the causative organism and guide treatment.
Choice B rationale:
Positioning the head of bed at 10 degrees is not beneficial for pneumonia patients.
Choice C rationale:
Coughing and deep breathing every 8 hours is not frequent enough for pneumonia patients.
Choice D rationale:
Encouraging fluid intake of 1500 mL/day is not sufficient for pneumonia patients.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma.
Which of the following findings should the nurse identify as a safety risk?
Explanation
Choice A rationale:
Using a microwave for cooking is not a safety risk.
Choice B rationale:
Electrical cords along the walls are not a safety risk.
Choice C rationale:
Handrails in the bathroom are not a safety risk.
Choice D rationale:
Scatter rugs in the kitchen can cause falls, hence they are a safety risk.
A nurse is caring for a client who has a new diagnosis of urolithiasis.
Which of the following should the nurse identify as an associated risk factor?
Explanation
Choice A rationale:
Family history is not a risk factor for urolithiasis.
Choice B rationale:
A BMI less than 25 is not a risk factor for urolithiasis.
Choice C rationale:
Hypocalcemia is not a risk factor for urolithiasis.
Choice D rationale:
Diuretic use can lead to dehydration, which is a risk factor for urolithiasis.
A nurse is caring for a client.
Diagnostic Results: Admission: 12 hr later.
Lithium level 1.8 mEq/L (less than 1.5 mEq/L). Glucose level 90 mg/dL (74 to 106 mg/dL). Sodium 133 mEq/L (135 to 145 mEq/L). Lithium level 1.2 mEq/L (less than 1.5 mEq/L). Glucose level 80 mg/dL (74 to 106 mg/dL). Sodium 134 mEq/L (135 to 145 mEq/L). Vital Signs: Admission: Temperature 37.7° C (99.9° F). Respiratory rate 18/min.
Pulse rate 84/min.
BP 130/84 mm Hg. 12 hr later: Temperature 37° C (98.6° F). Respiratory rate 16/min.
Pulse rate 96/min.
BP 88/50 mm Hg. Nurses Notes: Admission: Gastrointestinal upset.
Uncoordinated gait.
12 hr later: Client fell asleep during assessment.
Client reports blurred vision.
Pale, dry mucous membranes.
Urine output 40 mL/hr. The nurse is collecting data from the client 12 hr later.
How should the nurse interpret the following findings? For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.
Findings 12 hr Later:. Vision.
Lithium level.
Urine output.
Mucous membranes.
Vital signs.
Explanation
Here’s how the nurse should interpret the findings 12 hr later: Vision (blurred): This is an indication of a potential worsening condition. Blurred vision can be a side effect of lithium toxicity. Lithium level (1.2 mEq/L): This is an indication of potential improvement. The lithium level has decreased from 1.8 mEq/L to 1.2 mEq/L, which is within the therapeutic range. Urine output (40 mL/hr): This is an indication of potential improvement. A urine output of 40 mL/hr is within the normal range, indicating adequate kidney function. Mucous membranes (pale, dry): This is an indication of a potential worsening condition. Pale, dry mucous membranes can be a sign of dehydration, which can affect lithium levels in the body. Vital signs (Temperature 37° C (98.6° F), Respiratory rate 16/min, Pulse rate 96/min, BP 88/50 mm Hg): This is an indication of a potential worsening condition. The client’s blood pressure has dropped significantly, which could be a sign of dehydration or another underlying issue.
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?
Explanation
Choice A rationale:
Positive Kernig’s sign is a clinical sign of meningitis, not specifically increased ICP12.
Choice B rationale:
Photophobia, or light sensitivity, is a symptom of meningitis but does not specifically indicate increased ICP12.
Choice C rationale:
Nuchal rigidity, or neck stiffness, is another symptom of meningitis, not a specific indicator of increased ICP12.
Choice D rationale:
Restlessness can be a sign of increased ICP as it may indicate changes in mental status, a key symptom of increased ICP12.
A nurse is caring for an older adult client who is postoperative.
Nurses' Notes 0800: Client is 3 days postoperative.
Currently disoriented to time and place, oriented to self.
Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times.
Client attempts to get out of bed without assistance.
Changes in client's behavior began the prior evening, and the client has been awake most of the night.
Client has refused to eat or drink since the previous day.
Intake and output from the previous day: 250 mL intake, 2,500 mL output.
A call placed to the provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per the provider's prescription.
The client continues to be restless.
Vital Signs: Heart rate 115/min, Respiratory rate 20/min, BP 90/65 mm Hg, Temperature 38.6°C (101.5°F). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
Action to Take 1. Action to Take 2. Actions to Take:. Request a prescription for benzodiazepine.
Assist the client to identify coping skills.
Encourage the client to exercise.
Monitor the client's fluid intake and output.
Encourage family members to stay with the client.
Condition Most Likely Experiencing:. Potential Condition:. Depression.
Alzheimer's disease.
Delirium.
Generalized anxiety disorder.
Parameters to Monitor 1. Parameters to Monitor 2. Parameters to Monitor:. BUN level.
Sleep-wake cycle.
Weight loss.
Suicidal ideation.
Fall risk.
**. .
No explanation
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger.
The client reports working with a keyboard most of the time while at work.
The nurse suspects carpal tunnel syndrome.
Which of the following tests should the nurse request that the client perform?
Explanation
Choice Arationale:
Holding the right arm straight is not a specific test for carpal tunnel syndrome.
Choice Brationale:
Extending the right arm upward is not a recognized test for carpal tunnel syndrome.
Choice C rationale:
Holding the wrist at a 90-degree flexion is similar to Phalen’s test, a recognized diagnostic test for carpal tunnel syndrome.
Choice D rationale:
Flexing the right arm at the elbow is not a recognized test for carpal tunnel syndrome.
A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management.
Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?
Explanation
Choice A rationale:
An HbA1c value of 8.5% is above the recommended range for good glucose control.
Choice B rationale:
An HbA1c value of 6.3% is within the target range for people with diabetes, indicating good glucose control.
Choice C rationale:
An HbA1c value of 10% is significantly above the recommended range, indicating poor glucose control.
Choice D rationale:
An HbA1c value of 7.8% is above the recommended range for good glucose control.
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?
Explanation
Choice A rationale:
Painful and red-tinged urination could indicate a urinary tract infection or passing of a kidney stone, not necessarily a contraindication for an intravenous pyelogram.
Choice B rationale:
The end of a menstrual period does not affect the procedure.
Choice C rationale:
Adequate fluid intake is generally beneficial for kidney health.
Choice D rationale:
An allergy to shellfish might indicate an allergy to iodine, which is used in the contrast dye for an intravenous pyelogram. This is a potential contraindication for the procedure and should be reported to the provider.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
Explanation
Choice A rationale:
Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine, leading to dehydration.
Choice B rationale:
Bradycardia is not a typical finding in diabetes insipidus.
Choice C rationale:
Polyphagia (excessive hunger) is more commonly associated with diabetes mellitus, not diabetes insipidus.
Choice D rationale:
Hyperglycemia is a symptom of diabetes mellitus, not diabetes insipidus.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
Explanation
Choice A rationale:
Whole milk is a good source of calcium and vitamin D, but it is not high in iron.
Choice B rationale:
Black tea contains tannins, which can inhibit iron absorption.
Choice C rationale:
Raisins contain some iron, but not as much as other food options.
Choice D rationale:
Black beans are a good source of iron, and consuming them can help increase iron levels in the body, which can alleviate symptoms of iron deficiency anemia.
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?
Explanation
Choice A rationale:
Flexing her ankles is a safe action that promotes blood flow and prevents clot formation.
Choice B rationale:
Massaging her legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Elevating her feet improves venous return, reducing the risk of VTE.
Choice D rationale:
Ambulating soon after surgery promotes blood flow and prevents clot formation.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest.
While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Explanation
Choice A rationale:
Airway obstruction is the immediate life-threatening risk due to swelling and blistering in the airway.
Choice B rationale:
Paralytic ileus is a potential complication, but it is not the immediate priority.
Choice C rationale:
Infection is a risk due to loss of skin integrity, but it is not the immediate priority.
Choice D rationale:
Fluid imbalance is a risk due to fluid loss from the burns, but airway management is the immediate priority.
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour.
Which of the following actions should the nurse take first?
Explanation
Choice A rationale:
Irrigating the catheter may be necessary, but it is not the first action to take.
Choice B rationale:
Notifying the provider is important, but there are actions the nurse can take first.
Choice C rationale:
Checking the tubing for kinks is the first action because it is a simple and non-invasive intervention.
Choice D rationale:
Adjusting the rate of the bladder irrigant may be necessary, but it is not the first action to take.
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?
Explanation
Choice A rationale:
Hypokalemia, or low potassium levels, is not typically associated with nephrotic syndrome or corticosteroid therapy.
Choice B rationale:
Hypomagnesemia, or low magnesium levels, is not a common side effect of corticosteroid therapy or a typical finding in nephrotic syndrome.
Choice C rationale:
Hypermagnesemia, or high magnesium levels, is also not a common finding in nephrotic syndrome or a side effect of corticosteroid therapy.
Choice D rationale:
Hyperkalemia, or high potassium levels, can occur in nephrotic syndrome due to the loss of albumin in the urine, which can lead to a decrease in the amount of calcium available to bind with potassium, resulting in an increase in serum potassium levels. Additionally, corticosteroids can cause sodium retention and potassium excretion, leading to hyperkalemia.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
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