ATI NCLEX Prep Review Questions with Answers Graded A
Since oxygen is combustible, the following nursing ac-
tions are important for the nurse to implement: Post ""No
Smoking"" or ""Oxygen in Use"" signs to alert others of the
fire hazard. Know where to find the closest fire extinguish-
A client is receiving home oxygen. What teaching points er. Educate about the fire hazard of smoking with oxygen
should the nurse provide the client and the caregiver use. Have clients wear a cotton gown because synthetic or
regarding home oxygen safety? wool fabrics can generate static electricity. Ensure that all
electric devices (razors, hearing aids, radios) are working
well. Make sure all electric machinery (monitors, suction
machines) is grounded. Do not use volatile, flammable
materials (alcohol, acetone) near clients receiving oxygen.
The purpose of advance directives is to communicate a
client's wishes regarding end-of-life care should the client
become unable to do so. The PSDA requires asking all
clients on admission to a health care facility whether they
How should the nurse respond when a client asks the
have advance directives. Statt should give clients who do
purpose of an advance directive?
not have advance directives written information that out-
lines their rights related to health care decisions and how
to formulate advance directives. A health care representa-
tive should be available to help with this process.
Prolonged exposure to airborne micro-organisms can
make sterile items non-sterile.
List at least three (3) priority considerations when per- Avoid coughing, sneezing, and talking directly over a ster-
forming a sterile dressing change. ile field.
Air movement should be controlled by special ventilation.
Only sterile items may be in a sterile field.
Complications of constipation include: Fecal impaction.
A nurse is caring for an elderly client with constipation.
Development of hemorrhoids or rectal fissures. Bradycar-
What are three (3) complications to monitor for during
dia, hypotension, and syncope associated with the Valsal-
care of this client?
va maneuver (occurs with straining/bearing down).
A nurse is caring for a client with severe nausea and vomit-
ing. What are manifestations of possible dehydration and
, Manifestations of dehydration include: hyperthermia (de-
hydration), tachycardia, thready pulse, hypotension, or-
thostatic hypotension, decreased central venous pres-
sure, tachypnea (increased respirations), hypoxia, dizzi-
ness, syncope, confusion, weakness, fatigue; seizures
(rapid/severe dehydration), thirst, dry mucous mem-
branes, dry furrowed tongue, nausea, vomiting, anorexia,
acute weight loss, oliguria, diminished capillary refill, cool
clammy skin, diaphoresis, sunken eyeballs, flattened neck
veins, absence of tears, decreased skin turgor
Risk factors that can cause a decrease in medication ettec-
A nurse is reviewing medications while preparing to ad-
tiveness include increase body weight, genetics, tolerance
minister morning medications. List three (3) risk factors
to the medication, inadequate gastric acid, diarrhea, vas-
that can cause a decrease in medication ettectiveness.
cular insuflciency, and prolonged gastric emptying time.
Passive: Antibodies are produced by an external source.
Temporary immunity that does not have memory of past
exposures. Intact skin, the body's first line of defense.
Mucous membranes, secretions, enzymes, phagocytic
cells, and protective proteins. Inflammatory response with
phagocytic cells, the complement system, and interferons
Discuss passive and active immunity.
to localize the invasion and prevent its spread
Active: Antibodies are produced in response to an antigen.
Requires time to react to antigens. Provides permanent
immunity. Involves B- and T-lymphocytes. Produces specif-
ic antibodies against specific antigens (immunoglobulins
[IgA, IgD, IgE, IgG, IgM])
Instruct client to report all other the counter medications;
A client is prescribed a protease inhibitor—ritonavir. except for indinavir, take protease inhibitors with food to
Identify three (3) nursing considerations when adminis- increase absorption; administer with another antiretrovi-
tering a protease inhibitor. ral; advise barrier form of contraception; advise diet high
in calcium and vitamin D.
Since oxygen is combustible, the following nursing ac-
tions are important for the nurse to implement: Post ""No
Smoking"" or ""Oxygen in Use"" signs to alert others of the
fire hazard. Know where to find the closest fire extinguish-
A client is receiving home oxygen. What teaching points er. Educate about the fire hazard of smoking with oxygen
should the nurse provide the client and the caregiver use. Have clients wear a cotton gown because synthetic or
regarding home oxygen safety? wool fabrics can generate static electricity. Ensure that all
electric devices (razors, hearing aids, radios) are working
well. Make sure all electric machinery (monitors, suction
machines) is grounded. Do not use volatile, flammable
materials (alcohol, acetone) near clients receiving oxygen.
The purpose of advance directives is to communicate a
client's wishes regarding end-of-life care should the client
become unable to do so. The PSDA requires asking all
clients on admission to a health care facility whether they
How should the nurse respond when a client asks the
have advance directives. Statt should give clients who do
purpose of an advance directive?
not have advance directives written information that out-
lines their rights related to health care decisions and how
to formulate advance directives. A health care representa-
tive should be available to help with this process.
Prolonged exposure to airborne micro-organisms can
make sterile items non-sterile.
List at least three (3) priority considerations when per- Avoid coughing, sneezing, and talking directly over a ster-
forming a sterile dressing change. ile field.
Air movement should be controlled by special ventilation.
Only sterile items may be in a sterile field.
Complications of constipation include: Fecal impaction.
A nurse is caring for an elderly client with constipation.
Development of hemorrhoids or rectal fissures. Bradycar-
What are three (3) complications to monitor for during
dia, hypotension, and syncope associated with the Valsal-
care of this client?
va maneuver (occurs with straining/bearing down).
A nurse is caring for a client with severe nausea and vomit-
ing. What are manifestations of possible dehydration and
, Manifestations of dehydration include: hyperthermia (de-
hydration), tachycardia, thready pulse, hypotension, or-
thostatic hypotension, decreased central venous pres-
sure, tachypnea (increased respirations), hypoxia, dizzi-
ness, syncope, confusion, weakness, fatigue; seizures
(rapid/severe dehydration), thirst, dry mucous mem-
branes, dry furrowed tongue, nausea, vomiting, anorexia,
acute weight loss, oliguria, diminished capillary refill, cool
clammy skin, diaphoresis, sunken eyeballs, flattened neck
veins, absence of tears, decreased skin turgor
Risk factors that can cause a decrease in medication ettec-
A nurse is reviewing medications while preparing to ad-
tiveness include increase body weight, genetics, tolerance
minister morning medications. List three (3) risk factors
to the medication, inadequate gastric acid, diarrhea, vas-
that can cause a decrease in medication ettectiveness.
cular insuflciency, and prolonged gastric emptying time.
Passive: Antibodies are produced by an external source.
Temporary immunity that does not have memory of past
exposures. Intact skin, the body's first line of defense.
Mucous membranes, secretions, enzymes, phagocytic
cells, and protective proteins. Inflammatory response with
phagocytic cells, the complement system, and interferons
Discuss passive and active immunity.
to localize the invasion and prevent its spread
Active: Antibodies are produced in response to an antigen.
Requires time to react to antigens. Provides permanent
immunity. Involves B- and T-lymphocytes. Produces specif-
ic antibodies against specific antigens (immunoglobulins
[IgA, IgD, IgE, IgG, IgM])
Instruct client to report all other the counter medications;
A client is prescribed a protease inhibitor—ritonavir. except for indinavir, take protease inhibitors with food to
Identify three (3) nursing considerations when adminis- increase absorption; administer with another antiretrovi-
tering a protease inhibitor. ral; advise barrier form of contraception; advise diet high
in calcium and vitamin D.
