NUR 2513 ati Practice Exam 2 Questions with Answers & Rationale (Verified 100% Correct)

  1. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs. Rationale: It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm. B. Request a dietitian consult. Rationale: While the dietitian might be able to assist the client with making appropriate food choices, this is not the first action the nurse should take. C. Suggest that the client rests before eating the meal. Rationale: While this intervention might be appropriate, this is not the first action the nurse should take. D. Request an order for an antiemetic. Rationale: While this intervention might relieve the client's nausea, this is not the first action the nurse should take. 2. A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level." Rationale: The effects of heparin begin within minutes. This response does not accurately answer the client's question. B. "A pharmacist is the person to answer that question." Rationale: Contacting the pharmacist is not the appropriate answer for the nurse to give. C. "Heparin does not dissolve clots. It stops new clots from forming." Rationale: This statement accurately answers the client's question. D. "The oral medication you will take after this IV will dissolve the clot." Rationale: This is not a correct response. Warfarin, a PO medication that is often started after the client has been on heparin, does not dissolve clots. 3. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued. B. "I will call the provider to get a prescription for discontinuing the IV heparin today." Rationale: Discontinuing the IV heparin is not indicated at this time. C. "Both heparin and warfarin work together to dissolve the clots." Rationale: Neither medication dissolves clots that have already formed. D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay." Rationale: Neither medication increases the effects of the other. 4. A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A. Asthma Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation. B. Glaucoma Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not contraindicated in a client who has glaucoma. C. Depression Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not contraindicated in clients who have depression. D. Migraines Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches. 5. A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication? A. Hyperthermia Rationale: Temperature is not affected by verapamil. B. Hypotension Rationale: Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be monitored before and during parenteral administration. C. Ototoxicity Rationale: Verapamil is not toxic to the ear. D. Muscle pain Rationale: Verapamil does not cause muscle pain. 6. A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? A. Decreased blood pressure Rationale: Lisinopril, an ACE inhibitor, may be used alone or in combination with other antihypertensives in the management of hypertension and congestive heart failure. A therapeutic effect of the medication is a decrease in blood pressure. B. Increase of HDL cholesterol Rationale: This is not an intended effect of lisinopril. C. Prevention of bipolar manic episodes Rationale: This is not an intended effect of lisinopril. D. Improved sexual function Rationale: This is not an intended effect of lisinopril. Lisinopril may in fact cause sexual dysfunction and impotence. 7. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? A. "I can walk a mile a day." Rationale: Improving the client's cardiac output, which in turn will improve the client's exercise tolerance, is a therapeutic response to digoxin. B. "I've had a backache for several days." Rationale: Backaches are not an adverse effect of digoxin. C. "I am urinating more frequently." Rationale: Improving the client's cardiac output, which in turn will increase blood flow to the kidneys and urination, is a therapeutic response to digoxin. D. "I feel nauseated and have no appetite." Rationale: Anorexia, nausea, vomiting, and abdominal discomfort are early signs of digoxin toxicity. 8. A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make? A. "Taking the medication between meals will help you avoid becoming constipated." Rationale: Taking the medication with food can reduce the GI symptoms associated with it. However, taking the medication between meals maximizes absorption. B. "Taking the medication with food increases the risk of esophagitis." Rationale: Reclining immediately after taking ferrous sulfate may lead to esophageal corrosion. Clients should remain upright for 15-30 min following administering. C. "Taking the medication between meals will help you absorb the medication more efficiently." Rationale: Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron supplements between meals helps to increase the bioavailability of the iron. D. "The medication can cause nausea if taken with food." Rationale: Taking ferrous sulfate with food can reduce the GI symptoms associated with it. However, taking the medication between meals maximizes absorption. 9. A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication? A. The leukocyte count Rationale: Epoetin alfa does not affect the leukocyte, or WBC, count. B. The platelet count Rationale: An increase in platelets is not the therapeutic or desired effect of epoetin alfa. C. The hematocrit (Hct) Rationale: Epoetin alfa is an antianemic medication that is indicated in the treatment of clients who have anemia due to reduced production of endogenous erythropoietin, which may occur in clients who have end-stage renal disease or myelosuppression from chemotherapy. The therapeutic effect of epoetin alfa is enhanced red blood cell production, which is reflected in an increased RBC, Hgb, and Hct. D. The erythrocyte sedimentation rate (ESR) Rationale: Epoetin alfa does not affect the ESR, which is a measurement of inflammation. 10. A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A. Leave the client 5 min after beginning the transfusion. Rationale: The nurse should remain with the client for 15 to 30 min after the start of the transfusion to monitor for a reaction, which usually occurs during the first 50 mL of the transfusion. B. Infuse the transfusion at a rate of 200 mL/hr. Rationale: The transfusion should infuse in 2 to 4 hr to prevent fluid overload. C. Check the client's vital signs every hour during the transfusion. Rationale: The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction. D. Flush the blood tubing with dextrose 5% in water. Rationale: The nurse should flush the blood tubing with 0.9% sodium chloride to prevent hemolysis of the blood. 11. A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction? A. Client report of low back pain Rationale: Manifestations of an acute hemolytic reaction include apprehension, tachypnea, hypotension, chest pain, and lower back pain. B. Client report of tinnitus Rationale: Tinnitus is a manifestation of ototoxicity and is an adverse effect of aminoglycoside antibiotics. C. A productive cough Rationale: A cough is a manifestation of circulatory overload. D. Distended neck veins Rationale: Distended neck veins are a manifestation of circulatory overload. 12.A A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching? A. "Clients who have glaucoma should not take warfarin." Rationale: Liver disease is a contraindication for warfarin therapy. B. "Clients who have rheumatoid arthritis should not take warfarin." Rationale: Thrombocytopenia is a contraindication for warfarin therapy. C. "Clients who are pregnant should not take warfarin." Rationale: Warfarin therapy is contraindicated in the pregnant client because it crosses the placenta and places the fetus at risk for bleeding. D. "Clients who have hyperthyroidism should not take warfarin." Rationale: Peptic ulcer disease is a contraindication for warfarin therapy 13. A nurse is assessing an older adult client who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin toxicity? A. Anorexia Rationale: Anorexia, vomiting, confusion, headache, and vision changes are manifestations of digoxin toxicity. B. Ataxia Rationale: Ataxia (lack of muscle coordination) is a manifestation of benzodiazepine toxicity. C. Photosensitivity Rationale: Digoxin toxicity causes halos around lights. Photosensitivity is a manifestation of NSAID toxicity. D. Jaundice Rationale: Jaundice is a manifestation of sulfonylurea toxicity. 14. A nurse is teaching a client who has a new prescription for colesevelam to lower his low-density lipoprotein level. Which of the following instructions should the nurse include? A. "Take this medication 4 hr after other medications." Rationale: The client should take this medication 4 hours after other medications to increase absorption of the medication. B. "Reduce fluid intake." Rationale: The client should increase fiber and fluid intake to reduce the risk for constipation. C. "Take this medication on an empty stomach." Rationale: The client should take the medication with meals. D. "Chew tablets before swallowing." Rationale: The client should swallow tablets whole to increase absorption. 15. A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? A. Systolic blood pressure is increased Rationale: When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases systolic blood pressure. B. Cardiac output is reduced Rationale: A therapeutic effect of low-dose dopamine is increased cardiac output. C. Apical heart rate is increased Rationale: Tachycardia is an adverse effect, not a therapeutic effect, of dopamine. D. Urine output is reduced Rationale: A therapeutic effect of low-dose dopamine is increased urine output. Decreased urine output at high doses is an adverse effect of dopamine. 16.A A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take? A. Use a 22-gauge needle to inject the medication. Rationale: The nurse should use a small needle, 25- or 26-gauge, to administer the heparin. B. Use a 1-inch needle to inject the medication. Rationale: The nurse should use a short needle, 3/8 inch or smaller, to administer the heparin. C. Inject the medication into the abdomen above the level of the iliac crest. Rationale: The nurse should inject the medication into the abdomen above the level of the iliac crest, at least 2 inches from the umbilicus. D. Massage the injection site after administration of the medication. Rationale: The nurse should apply firm pressure without massage to the site for 1 to 2 min after administration. Massaging the area after injecting heparin can cause bleeding. 17.A A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? A. "A headache is an indication of an allergy to the medication." Rationale: Allergic reactions typically manifest as itching and a rash, and if worsening, laryngeal edema and bronchospasm. B. "A headache is an expected adverse effect of the medication." Rationale: The vasodilation nitroglycerin induces increases blood flow to the head and typically results in a headache. C. "A headache indicates tolerance to the medication." Rationale: With tolerance, the client needs more of the medication to achieve a therapeutic response. A headache is not a sign of this phenomenon. D. "A headache is likely due to the anxiety about the chest pain." Rationale: This is a nontherapeutic communication technique and offers the nurse's opinion about the cause of the headache rather than a factual statement. 18.A A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching? A. Apply a new transdermal patch once a week. Rationale: The client should apply a new patch each day, not once a week. B. Apply the transdermal patch in the morning. Rationale: The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening. C. Apply the transdermal patch in the same location as the previous patch. Rationale: The client should rotate the sites used for patch placement to avoid areas of local skin irritation. D. Apply a new transdermal patch when chest pain is experienced. Rationale: The transdermal route of nitroglycerin has a delayed onset of action, making it suitable for prophylaxis use but not for immediate relief of chest pain. 19.A A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client? A. Aspirin Rationale: Although aspirin has anticoagulant effects, clients generally take it for ongoing primary prevention of cardiovascular and cerebrovascular events, not for the immediate anticoagulant effects a client who is postoperative hip arthroplasty requires. B. Clopidogrel Rationale: Clopidogrel is an oral antiplatelet drug clients take to prevent stenosis of coronary stents and for some secondary prevention indications, not for the immediate anticoagulant effects a client who is postoperative hip arthroplasty requires. C. Enoxaparin Rationale: The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery. D. Alteplase Rationale: Alteplase is a thrombolytic agent used in clients experiencing an acute MI, acute ischemic stroke, or acute massive PE. 20.A A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? A. Vitamin K Rationale: Vitamin K reverses the effects of warfarin, not heparin, by promoting the synthesis of coagulation factors VI, IX, X, and prothrombin. B. Protamine sulfate Rationale: Protamine sulfate reverses the effects of heparin by binding with heparin to form a heparin-protamine complex that has no anticoagulant properties. C. Acetylcysteine Rationale: Acetylcysteine, a mucolytic, reduces the risk of hepatotoxicity after acetaminophen overdose. It does not reverse the effects of heparin toxicity. D. Deferasirox Rationale: A chelating agent such as deferasirox binds to iron to reduce iron toxicity from supplemental iron therapy. It does not reverse the effects of heparin toxicity. 21.A A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? A. "Take this medication after each meal and at bedtime." Rationale: The client should take nitroglycerin tablets on a PRN basis, not routinely at specific times. B. "Take one tablet every 15 min during an acute attack." Rationale: If one tablet does not relieve the client's pain, he should access emergency services and then take two more at 5-min intervals if he still has pain. C. "Take one tablet at the first indication of chest pain." Rationale: The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and not wait until his chest pain is severe. D. "Take this medication with 8 ounces of water." Rationale: Nitroglycerin tablets are sublingual. The client should place them under the tongue, not swallow them with water. 22. A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? A. Potassium Rationale: Furosemide is a loop diuretic that promotes the excretion of potassium. The nurse should monitor the client's potassium level to watch for hypokalemia. B. Albumin Rationale: Furosemide does not affect albumin levels. C. Cortisol Rationale: Furosemide does not affect cortisol levels, although it can lower serum sodium levels. D. Bicarbonate Rationale: Furosemide does not affect bicarbonate levels. 23.A A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include? A. "Limit your fluid intake to meal times." Rationale: The nurse should instruct the client to increase fluid intake rather than limit intake to meal times due to the potential adverse effect of constipation. B. "Do not take this medication on an empty stomach." Rationale: The nurse should instruct the client that verapamil can be taken without food. C. "Increase your daily intake of dietary fiber." Rationale: The nurse should instruct the client to increase his daily intake of dietary fiber to reduce the risk of constipation associated with verapamil. D. "You can expect swelling of the ankles while taking this medication." Rationale: The nurse should instruct the client to report any swelling of the ankles or feet to the provider immediately, as these are manifestations of an adverse effect. 24.A A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? A. Offer the client a light snack. Rationale: The client can take the medication with or without food, although giving it immediately after food can delay absorption slightly. B. Measure the client's blood pressure. Rationale: It is not necessary to measure blood pressure immediately before dosing, but the nurse should monitor the client's blood pressure routinely. C. Measure the client's apical pulse. Rationale: Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 min before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected. D. Weigh the client. Rationale: It is not necessary to weigh the client immediately before dosing, but the nurse should monitor the client's weight routinely. 25.A A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? A. "Take only one dose of nitroglycerin to reduce the risk of getting a headache." Rationale: Sublingual nitroglycerin may be taken up to three times, five minutes apart. Reducing the number of doses may not relieve the angina pain. B. "There's nothing that can be done to relieve the headaches that nitroglycerin causes." Rationale: The headaches associated with nitroglycerin use diminish over time. Until then, headaches can be relieved by mild analgesics. C. "Try taking a mild analgesic to relieve the headache." Rationale: Headache is a common side effect of nitroglycerin. The nurse should suggest conservative measures, such as taking aspirin, acetaminophen, or some other mild analgesic, to manage the headache. Generally, headaches that are a side effect of nitroglycerin are transient. D. "We will ask the provider to prescribe a different medication for you."