PHS 123 ati proct A questions and answers

A 1. A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. contractions b. Hypertention c. Epigastric pain d. vomiting Answer: a. Contraction Rational: Amniocentesis -Can't be done before 16 weeks, not enough amniotic fluid. -maternal risks: hemorrhage, feto maternal hemorrhage, infection, contractions/labor, abruptio placentae, damage to intestines or bladder, amniotic fluid embolism -fetal risks: death, hemorrhage, infection, direct injury from the needle, miscarriage, and preterm, leakage of amniotic fluid 2. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Stay in bed at least 1 hr if unable to fall asleep. b. Take a 1 hr nap during the day c. Perform exercises prior to bedtime d. Eat a light snack before bedtime Answer:D. Eat a light snack before bedtime Rational:Consume a light snack of carbohydrates at bedtime 3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor displays ventricular tachycardia. Which of the following actions should the nurse first take determining the client does not have a palpable pulse? a. Assess heart sounds b. Defibrillate c. Establish IV access d. Administer Epinephrine Answer:B. Defibrillate Rational: The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular tachycardia with a pulse is amiodarone. If the client is pulseless or nonresponsive, the client is unstable and defibrillation is used 4. A nurse is admitting a client who is one week postpartum and reports excessive vaginal bleeding. The nurse does not speak the same language as the client the client’s partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client’s admission data? a. Have the client’s child translate b. Allow the client’s partner to translate c. Request a female interpreter through the facility d. Ask a nursing student who speaks the same language as the client to translate. Answer: C. Request a female interpreter through the facility Rational: We been told not to use family members if not facility interpreters 5. A nurse is caring for a client who is febrile(fever). To reduce the client’s fever, the nurse applies cooling. Which of the following indicates the client is having an adverse reaction to the cooling? a. Flushing b. Tachycardia c. Restlessness d. Shivering Answer: D. shivering Rational: Hypothermia is the adverse reaction of cooling system for a febrile patient s/s of hypothermia: shivering, slurred speech, weak pulse drowsiness, confusion, loss of memory 6. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? The Answer should be: ensure that the lower extremity is elevated. Rational: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus 7. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian? a. An older adult client who has BMI of 24 b. A client who has a nonhealing leg ulcer c. An older adult client who had presbyopia d. A client who has an albumin level of 3.7 g/dl Answer:B. A client who has a nonhealing leg ulcer Rational: type of patients that can be referred to dietitian are the ones that present: Physical S&S Malnutrition Hair is dull, brittle, dry, or falls out easily Swollen glands of neck and cheeks Dry, rough, or spotty skin Poor or delayed wound healing or sores Thin appearance with lack of subcutaneous fat Muscle wasting Edema of lower extremities Weakened hand grasp Depressed mood Abnormal heart rate/rhythm and BP Enlarged liver or spleen Loss of balance and coordination Presbyopia: farsighted 8. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1g/kg of protein per day b. Take magnesium hydroxide for indigestion c. Drink at least 3 L of fluid daily. d. Consume foods high in K+ Answer: A. Eat 1g/kg of protein per day Rational: Protein intake and hemodialysis protein is not routinely restricted. Magnesium hydroxide. Please don’t chose this anwer! -Magnesium is excreted by the kidneys, and patients with CKD should not use OTC products containing magnesium. The other mediations are appropriate for a patient with CKD. 9. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. Sitting in high-fowlers position during the feeding b. History of gastroesophageal reflux disease (GERD) c. Receiving a high osmolality formula d. A residual of 65ml 1 hr postprandial Answer: B. History of gastroesophageal reflux disease (GERD) Rational: Pt with higher Risk of aspiration a in clients with GERD 10. A nurse is providing prenatal teaching to a client who is 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening test at 16 weeks of gestation? a. Chorionic villus sampling b. Cervical cultures for chlamydia c. Non-stress test d. Maternal serum alpha-fetoprotein Answer: D.Maternal serum alpha-fetoprotein(performed ideally at 16 to 18 weeks) Rational: Screening is usually done by taking a sample of your blood between 15 and 20 weeks of pregnancy (16 to 18 weeks is ideal). The multiple markers include: AFP screening. Also called maternal serum AFP, this blood test measures the level of AFP in your blood during pregnancy. High levels of alpha-fetoprotein: May indicate neural tube defects, anencephaly or abdominal wall defect. Would follow up with ultrasound. 11. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels b. Increased blood pressure c. Swollen area on calf d. Urinary frequency Answer: C. Swollen area on calf Rational: primary and serious effects of immobility on the musculoskeletal system atrophy (decreased muscle size); contractures; ankylosis (fixation of a joint); osteoporosis (loss of bone density); footdrop (plantar flexion) 12. A nurse in an acute care mental health facility is participating in a medication- education group. The leader of the group uses laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session? a. The leader encourages group members to remain silent until questions are called for. b. The leader lectures about medication adverse rxn to the group members. c. The leader allows the group to discuss whatever they would like regarding their medications. d. The leader has group members vote on what they would like to learn about during the session. Answer: C. The leader allows the group to discuss whatever they would like regarding their medications. Rational: Laissez-Faire leader gives up control with free-run or permissive style 13. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? a. “You can add the medication to a half-cup of your child’s favorite juice” b. “Repeat the dose if your child vomits within1 hour after taking the medication.” (u don’t suppose to re administer, even if the dose is missed) c. “Limit your child’s potassium intake while she is taking this medication.” d. “Have your child drink a small glass of water after swallowing the medication.” answer:D. “Have your child drink a small glass of water after swallowing the medication.” .”(to prevent tooth decay if child has teeth) Rational: make the child to drink water and Brush the child's teeth after giving the medication 14. A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid? a. Grapefruit b. Spinach c. Cottage Cheese d. Smoked Salmon Answer:D. Smoked Salmon Rational: Foods to avoid/restrict Avocados, bananas, raisins, papaya, canned figs fava beans cheese (cottage okay), sour cream, yogurt beer, wine (esp. red) beef or chicken liver, pate, m