ATI-ADVANCED-MED-SURG-PROTECTED-2023-EXAM LATEST VERSION 100% -CORRECT AND DETAILED ANSWER AND QUESTIONS

ATI Advanced MED SURG Proctored 2023 WITH Glasgow COMA Scale REAL EXAM Studocuisnotsponsoredorendorsedbyanycollegeor university ATIADVANCEDMEDSURGPROCTORED2023WITHGLASGOW COMASCALEREALEXAM 1. Anurseinaburntreatmentcenteriscaringforaclientwhoisadmittedwithsevereburnsto bothlowerextremitiesandispendinganescharotomy.Theclient’sspouseasksthenursewh attheprocedureentails.Whichofthefollowing nursingstatementsisappropriate? a. “largeincisionswillbemadeintheeschartoimprovecirculation” b. “Icancallthedoctorbackhereifyouwantmeto” c. “apieceofskinwillberemovedandgraftedovertheburnedarea” d. “deadtissuewillbesurgicallyremoved” 2. Anurseismonitoringthefluidreplacementofaclientwhohassustainedburns.Whichoft hefollowingfluidsisusedinthefirst24hoursfollowingaburninjury? a. 5%dextroseinwater b. 5%dextroseinnormalsaline c. normalsaline tedringers 3. Anurseiscaringforaclientwhohasfullthicknessburnsallover75%ofhisbody.Whichofthefollowingmethodsisappropriatetoa ccuratelymonitorthecardiovascularsystem? a. auscultatecuffbloodpressure b. palpatepulsepressure nacentralvenouspressure d. monitorthepulmonaryarterypressure 4. Anurseisassessingthedepthandextentofaclientwhohassevereburnstotheface,neck,an dupperextremities.Whichofthefollowingfactorsisthefirstprioritywhenassessingtheseve rityoftheburn? a. Ageoftheclient b. Associatedmedicalhistory c. Locationoftheburn d.Causeoftheburn 5. Aclientarrivesattheemergencydeptfollowinganexplosionatthechemicalplant.Heha sdeeppartialandfullthicknesschemicalburnsovermorethan25%ofhisbodysurfacearea.Whatisthenurse’s priorityintervention? a. Initiatefluidresuscitation b. Medicationforpain c. Administerantibiotics d.Maintainapatentairway 6. Anurseiscaringforaclientwhocametheemergencydeptreportingchestpain.Theprovider suspectsamyocardialinfarction.Whilewaitingforthelaboratorytoreporttheclient’stropon inlevels,theclientaskswhatthisbloodtestwillshow. Thenurseshouldexplainthattroponinis a. Anenzymethatindicatesdamagetobrain,heart,andskeletalmuscletissues b. Aproteinwhoselevelsreflecttheriskforcoronaryarterydisease c.Aheartmuscleproteinthatappearsinthebloodstreamwhenthereisdamagetot heheart d. Aproteinthathelpstransportoxygenthroughoutthebody 7. Anurseisassessingaclientwhohasdisseminatedintravascularcoagulation(DIC). Whichofthefollowingshouldthenurseexpectinthefindings? a. Excessivethrombosisandbleeding b. Progressiveincreaseinplateletproduction c. Immediatesodiumandfluidretention d.Increasedclottingfactors 8. Anurseisabouttoadministerwarfarin(Coumadin)toaclientwhohasatrialfibrillatio n.Whentheclientaskswhathismedicationwilldo,whichofthefollowingisanappropriat enursingresponse? a. Ithelpsconvertatrialfibrillationtosinusrhythm b. Isdissolvesclotsinthebloodstream c. Itslowstheresponseoftheventriclestothefastatrialimpulses d.Itpreventsstrokesinclientswhohaveatrialfibrillation 9. Anurseinacardiaccareunitiscaringforaclientwithacuteheartfailure.Whichofthefollo wingfindingsshouldthenurseexpect? a. Decreasedbrainnatriureticpeptide(BNP) b.Elevatedcentralvenouspressure(CVP) c. Decreasedpulmonarypressure d. Increasesurinaryoutput 10. AclientcomesintotheEDreportingnauseaandvomitingthatworsenswhenlyingdowna ndwithoutrelieffromantacids.Theprovidersuspectsacutepancreatitis.Whichofthefollow inglabtestresultsshouldthenurseexpecttoseeiftheclienthasacutepancreatitis? a. DecreasedWBC b.Increasedserumamylase c. Decreasedserumlipase d. Increasedserumcalcium 11. AnurseintheICUiscaringforaclientwhohasacuterespiratorydistresssyndrome( ARDS)andisreceivingmechanicalviaanendotrachealtube.Theproviderplanstoextub ateherwithinthenext24hour.Whichofthefollowingisanimportantcriterionforextubat ingtheclient? a. Abilitytocougheffectively b.Adequatetidalvolumewithoutmanuallyassistedbreaths c. Noindicationofinfection d. Noneedforsupplementaloxygen 12. AnurseiscaringforaclientfollowingaCTscanwithdyewhosufferedfromananaphylact icreaction.Whichofthefollowingconditionsrequiresaprioritynursingresponse? a. urticaria or c. tachypnea d. angioedema 13. AnurseiscaringforafemaleclientwhocameintotheEDreportingSOBandpaininthelun garea.Herheartrateis110/min,40/min,andbloodpressure140/80m8juiimHg.H erarterialbloodgasesare:pH7.5,PaCO229mmHg,PaO260mmHg,HCO320mEq/L,and SaO286%.Whichofthefollowingisthepriorityintervention? a. Prepareformechanicalventilation b.Administeroxygenviafacemask c. Preparetoadministerasedative d. Monitorforpulmonaryembolism 14. Anurseismonitoringaclientwhohasjusthadathoracentesistoremovepleuralfluid.Whic hofthefollowingclinicalmanifestationsindicateacomplicationthatrequiresnotifyingthepr oviderimmediately? a. Serosanguineousdrainagefromthepuncturesite b. Discomfortatthepuncturesite c.Increasedheartrate d. Decreasedtemperature 15. Agroupofcollegestudentswasattendingaweekendfootballrallywhenoneofthestuden tsstumbledandfellintothebonfire.Althoughseveralfriendsquickly intervened,theclientsustainedpartialthicknessburnstobothlowerlegs,chest,andbothforearms.Whichofthefollowingispriorit ynursingactionwhentheclientisbroughttotheED? a. covertheburnedareawithsterilegauze ctmouthforsignsofinhalation c. administerintravenouspainmedication d. drawbloodforaCBC 16. Atriagenurseinanemergencydeptiscaringforaclientwhohasgunshotwoundtotheri ghtsideofchest.Thenursenoticesthickdressingonthechestandsuckingnoisecomingfro mthewound.Theclienthasabloodpressureof100/60mmHg,aweakpulserateof118/min, andarespiratoryrateof40/min.Whichofthefollowingactionsshouldthenursetakeinitial ly? a. Raisethefootofthebedtoa90degreeangle b. Removethedressingtoinspectthewound c. Preparetoinsertacentralline d.Administeroxygenvianasalcannula 17. Anurseissuctioningtheendotrachealtubeofaclientwhoisonaventilator.Theclient’she art rate increasesfrom86/min to110/min andbecomesirregular. Thenurseshouldknowthattheclientrequireswhichofthefollowing? a. Acardiologyconsult b. Lessfrequentsuctioning c. Anantidysrhythmicmedication d.Pre-oxygenationpriortosuctioning 18. Thenurseiscaringforaclientwhoisreceivingabloodtransfusion.Thetransfusionst arted30minutesagoatarateof100mL/hr.Theclientbeginstocomplainoflowbackpaina ndheadacheandisincreasinglyrestless.Whatisthefirstnursingaction? a. Stopthetransfusion,disconnectthebloodtubing,andbeginaprimaryi nfusionofnormalsalinesolution b.Slowtheinfusionandevaluatethevitalsignsandtheclient’shistoryoftranfusi onreactions c.Slowtheinfusionofbloodandbegininfusionofnormalsalinesolutionfromthe Yconnector. d.Rechecktheunitofbloodforcorrectidentificationnumbersandcrossm atchinformation 19. Aclientwithadiagnosisofdisseminatedintravascularcoagulation(DIC)hasthefollowin gassessmentfindings:bloodpressureof76/56,temperature102.6 degrees,resp.24breath/min.,withcomplaintsofsevereneckandbackpain.Whichnursing actionshouldthenurseimplementfirst? a. Administeracetaminophen(Tylenol)PO. b.Administeribuprofen(Motrin)PO. c.DrawcoagulationstudybloodworkintheAM d.GivemorphinesulfateIV 20. Thenurseadministeringalbuterol(Proventil)viaametereddoseinhaler(MDI)toaclientwhohasahistoryofcoronaryarterydiseaseisnowincongestiveh eartfailure.Whatsideeffectswillbeparticularlyimportanttoobserveforwhentheclienttakest hemedication? a. Tremorsandcentralnervoussystemstimulation b.Tachycardiaandchestdiscomfort c.Developmentoforalcandidiasis d.Anincreaseinbloodpressure 21. Thenurseisassessingaclientwhoisonaventilatorandhasanendotrachealtubeinpla ce.Whatdataconfirmsthatthetubehasmigratedtoofarintothetrachea? a. Decreasedbreathsoundsareheardovertheleftsideofthechest b.Increasedrhonchiarepresentatthelungbasesbilaterally c.Ventilatorpressurealarmcontinuestosound d.Clientisabletospeakandcoughsexcessively 22. Whatisthedesiredactionofdopamine(Intropin)whenadministeredinthetreatmen tofshock? a. Itincreasesmyocardialcontractility b.Itisassociatedwithfewersevereallergicreactions c.Itcausesrapidvasodilationofthevascularbed d.Itsupportsrenalperfusionbydilationoftherenalarteries 23. ThenurseismonitoringanIVinfusionofsodiumnitroprusside(Nirpride).Fifteenminute safter the infusion isstarted,the client’sBP goesfrom190/120mmHgto120/90mmHg.Whatistheprioritynursingaction? a. RechecktheBPandcallthedoctor b.Decreasetheinfusionrateandrecheckthebloodpressurein5minutes c. StopthemedicationandkeeptheIVopenwithD5W. d. Assesstheclient’stoleranceofthecurrentlevelofBP 24. Norepinephrine(Levophed)hasbeenorderedforaclientinhypovolemicshock.Before administeringthedrug,thenurseshouldmakesurethattheclienthas: a. Aheartrateoflessthan120beats/min b. Urineoutputofatleast30mL/hr. c. Receivedadequateanticoagulation d.BeenreceivingadequateIVfluidreplacement 25. Theclientreturnstohisroomafterathoracotomy.Whatwillthenursingassessme ntrevealifhypovolemiafromexcessivebloodlossispresent? a. CVPof3cmH20andurineoutputof20mL/hr b.Jugularveindistentionwiththeheadelevated45degrees c.Chesttubedrainageof50mL/hrinthefirst2hours d.PersistentincreasedBPandincreasedpulsepressure 26. Thenurseisperforminganassessmentandfindstheclienthascold,clammyskin,puls eof130beats/minandweak,bloodpressureof84/56mmHg,andurinaryof20mLforthep asthour.Thenursewouldinterpretthesefindingsassuggestiveofwhichpathophysiolog y? a. Reductionofcirculationtothecoronaryarteries,thisincreasingthepreloa d b. Decreasedglomerulifiltrationrate,resultinginvolumeoverload c. Stimulationofthesympatheticnervoussystem,causingseverevasoc onstriction d.Decreaseinthecardiacoutputandinadequatetissueperfusion 27. ThenurseappliesaNitroDurpatchonaclientwhohasundergonecardiacsurgery.Whatnursingobservationindi catesthataNitro-Durpatchisachievingthedesiredeffect? a. Chestpainiscompletelyrelieved b.Clientperformsactivitiesofdailylivingwithoutchestpain c. Painiscontrolledwithfrequentchangesofpatch d. Clienttoleratesincreasedactivitywithoutpain 28) TheV/SofaclientwithCardiacdiseaseareasfollows:BP102/76mm/hg,Pulse52,RR16. AtropineisadministeredIVpush.Whatnursingassessmentindicatesatherapeuticresponset othemedication? A. Pulseratehasincreasedto70beats/min B.systolicBPhasincreasedby20 C.pupilsaredilated D.oralsecretionshavedecreased 29) AnolderadultclientcomesintoERstatingthathehasnoappetite,isnauseated,hisheartfe elsfunnyandhasnoticedahazinessinhisvision.Theclientstatesthathehasbeentakingananti hypertensivedruganddigitalisformorethanayear. Basedonthepresentingsymptoms,whatwouldbetheprioritynursingaction? A. ObtainanorderforanEKGandserumpotassiumanddigitalislevels B.Performaneurologicalassessmenttodeterminewhetherhehasonesideweakne ss. C.Assesslungsfordecreasedbreathsoundsand/oradventitiousbreathsounds . d.ObtainanorderforanEKG 30) thenurseisadministeringalteplasetoaclientwhohasbeendiagnosedwithacutecor onarysyndrome.Whatareimportantnursingimplicationsforthismedication? A. MonitortheECGfordysrthymias B.Placetheclientonbleedingprecautions C. monitorurineoutputhourly D. Monitorforactivitytolerance 31) Thenurseiscaringforaclientwhounderwentcardiaccatheterization1hourago.Wha tisanimportantnursingmeasureatthistime? A. Measureurinaryoutputhourlyandmaintaincontinuouscardiacmonitoring B. Encourageclienttoperformslowpressureexerciseoftheaffectedsidetopromot ecirculation. C.Maintainpressureovercatheterinsertionsiteanddeterminedistalcirculatio nstatus. D. Evaluateapicalpulseanddeterminepresenceofpulsedeficit. 32. Thenurseinacardiacstepdownunithasreceivedahandoffshiftreportfortheseclients.Whichclientshouldbeassessfirst? A. aclientwhohasjustreturnedfromacoronaryartierogramwithplacementofanintrac oronarystent. B.Aclientwhoisinheartfailureandhasgained2pndsinthelast24hours. C.aclientwithendocarditiswhohastemperatureelevationof100FandP100beats/mi n D.Aclientwhowascardiovertedfromatrialfib24hoursagoandhashad3atrialpremature 33) What ECG changes would reflect my ocardial is chemiain a client who has been admitted for observation after experiencing an episode of chestpain? A. ProlongedPRinterval B. Wide QRS complex C. ST-Segmentelevationordepression D. Tall,peakT-waves 34) A new employe eat a facility need sahepatitis vaccine.Which statement reflects accurate understanding of the immunization? A. Ineedtoget6shotsofhepC B. OnceIreceivetheHepvaccineIwillalwaysbeenimmune C.Iwillreceive3injectionsoveraperiodofmonths,whichshouldprotectmefromhepB D. HepvaccineisanoralvaccinewithliveattenuatedVirus 35) Whiletalkingwithaclientwithadiagnosisofendstageliverdisease.Thenursenoticesthe clientisunabletostayawakeandseemstofallasleepinthemiddleofasentence.Thenursereco gnizesthesesymptomstobeindicativeofwhatcondition? A. Hyperglycemia B. IncreasedBileproduction C.Increasedbloodammonialevels D. Hypocalcaemia 36) ThenurseiscaringforaclientwithchronichepB.Whatwilltheteachingplanforthisclie ntinclude? A. useacondomforsexualintercourse B.Reportanyclay-coloredstools. C.Eatahighproteindiet D.Performdailyurinebilirubinchecks 37. Apatientwithmassivetraumaandpossiblespinalcordinjuryisadmittedtotheemergencyd epartment(ED).Whichfindingbythenursewillhelpconfirmadiagnosisofneurogenicshock? a. coolclammyskin b. inspiratorycrackles lheartrateof48beats/min d. temperature101.2*F 38. Apatientwithsepticshockhasaurineoutputof20mL/hrforthepast3hours.Thepulserateis 120andthecentralvenousandpulmonaryarterywedgepressureare4.Whichoftheseordersby thehealthcareproviderwillthenursequestion? a. Givefurosemide(Lasix)40mgIV asenormalsalineinfusionto150mL/hr c.Administerhydrocortisone(SoluCortef)100mgIV d.Preparetogivedrotrecoginalpha(Xigris)24mcg/kg/hr 39. After receiving 1000m Lof normal saline, the central venous pressure for apatientwhohassepticshockis10mmHg,butthebloodpressureisstill82/40mmHg.Thenur sewillanticipatetheadministrationofwhichofthefollowing? a. Nitroglycerin(Tridil) b. Sodiumnitroprusside(Nipride) c. Drotrecoginalpha(Xigris) d. Norepinephrine(Levophed) 40. Whichofthesefindingsisthebestindicatorsthatthefluidresuscitationforapatientwi thhypovolemicshockhasbeensuccessful? a. hemoglobiniswithinnormallimits b.Urineoutputis60mLoverthelasthour c. Pulmonaryarterywedgepressure(PAWP)is10mmHg d. Meanarterialpressure(MAP)is55mmHg 41. Whichinterventionswillthenurseincludeintheplanofthecareforapatientwhohasca rdiogenicshock? a. Avoidelevatingheadofbed b. Checktemperatureevery2hours c.Monitorbreathsoundsfrequently d. Assessskinforflushinganditching 42. Whichassessmentismostimportantforthenursetomakeinordertoevaluatewhethertr eatmentofapatientwithanaphylacticshockhasbeeneffective? a. Pulserate b. Orientation c. Bloodpressure d.Oxygensaturation 43. Whencaringforthepatientwhohassepticshock,whichassessmentfindingismostimpor tantforthenursetoreporttothehealthcareprovider?(TBch.67Q.17) a. BP92/56mmHg b.Skincoolandclammy c. apicalpulse118beats/min d. Arterialoxygensaturation91% 44. Duringchange-ofshiftreport,thenurselearnsthatapatienthasbeenadmittedwithdehydrationandhypotensio nafterhavingvomitinganddiarrheafor3days.Whichfindingsismostimportantforthenurse toreporttotheHCP? a. Decreasedbowelsounds b. Apicalpulse110beats/min c. Pale,cool,anddryextremities d.Newonsetofconfusionandagitation 45. Apatientisadmittedtotheburnunitwithburnstheupperbodyandheadafteragaragefire.I nitially,wheezesareheard,butanhourlater,thelungsoundsaredecreasedadnowheezesarea udible.Whatisthebestactionforthenursetotake? a. encouragethepatienttocoughandauscultatethelungsagain b.NotifytheHCPandprepareforendotrachealintubation c. Documenttheresultsandcontinuetomonitorthepatient’ d. Repositionptinhigh-Fowler’spositionandreassessbreathsounds 46. Duringtheemergentphaseofburncare,whichnursingactionwillbemostusefulin determiningwhetherthepatientisreceivingadequatefluidinfusion? a. Checkskinturgor b. Monitordailyweight c. Assessmucousmembranes d.Measureshourlyurineoutput 47. Afterreceivingchange-ofshiftreport,whichofthesepatientsshouldthenurseassessfirst? a. Apatientwithsmokeinhalationwhohaswheezesandalteredmentalstatus b.Apatientwithfull-thicknesslegburnswhohasadressingchangescheduled c.Apatientwithabdominalburnswhoiscomplainingoflevel8(0to10scale)pain. d.Apatientwith40%totalbodysurfacearea(TBSA)burnswhoisreceivingIVfluidsat5 00mL/hr 48. TheRNobservesallofthefollowingactionsbegintakenbyastaffnursewhohasfloatedtot heunit.WhichactionrequiresthattheRNintervene? a. Thenurseuseslatexgloveswhenapplyingantibacterialcreamtoaburnwound b.Thefloatnurseobtainsburncultureswhenthepatienthasatempof101*F c.ThefloatnurseadministersPRNfentanyl(Sublimaze)IVtoapt5minutesbeforead ressingchange d.Thefloatnursecallsthehealthcareproviderforaninsulinorderwhenanondiabe ticpthasanelevatedserumglucose 49) Aclientwithcervicalneckfractureisadmittedtotheintensivecareunit.Whichfindingsw ouldthenurserecognizeasindicativeofspinalshock? A. Spastically,neuromuscularirritability,hyperreflexia B. Flaccidityandlackofsensationbelowthelevelofspinalcordlesion. C. Automaticdysreflexiawithneurogenicbladdersymptoms D. Muscularspasticityandlossofmotorreflexesinallpartsofthebodybelowthelevelofspi nalcordlesion. 50) AclientwithT6spinalcordinjuryisbeingdischarged.ThePTisconcernedaboutau tonomicdysreflexia.S/Sincludethefollowing: A. Dialitedpupils B. Suddenvomitinganddiarrhea C. dropinBPandpulse D.Diaphoresisabovethelevelofthelesion 51) Awomanhasbeenrecentlydiagnosedwithsystemiclupusandshareswiththenurse,Iwant togetpregnant,butIdon’tknowhowIwilltoleratepregnancybecauseIhavelupus.Whichresp onseisbest? A. Mostwomenfindthattheyfeelbetterwhentheyarepregnant B.Howlonghaveyoubeeninremission? C. Womenwithlupusfrequentlyhaveslightlylongergestation D. Itsbesttobecomepregnantwithinthefirst6monthsofdiagnosis 52. Thenurseisassessingthepatencyofanarteriovenousfistulaandsuspectsclottingi nthefistulaifwhichfindingarenoted?Selectallthatapply A. presenceofathrillonpalpationoverthefistula *B.Absenceofabruitonauscultationoverthefistula C.Presenceofapulseintheextremitybelowthefistula *D.Complaintsoftinglingordiscomfortintheextremity E.Warmhandandfingersintheextremityinwhichthefistulaislocated. 53. Epoetinalfa(Epogen)isprescribedforaclientdiagnosedwithchronicrenalfailure. Theclientasksthenurseaboutthepurposeofthemedication.Theappropriateresponsew ouldbewhichofthefollowing? A.Itisusedtoloweryourbloodpressure *B.Itisusedtotreatanemia C.Itwillhelptoincreasethepotassiumlevelsinyourbody D.Itisananticonvulsantmedicationgiventoallclientsafterdialysistopreventseizurea ctivity. 54. AclientwithandECGreadingshowingsinusbradycardiahasabloodpressureof47/28mm hg.Whichdrugsdoesthenurseexpectthephysiciantoorderforthisclient? A.Lidocaine(Xylocaine) *B.Atropinesulfate C.Isoproterenolhydrochloride(Isuprel) D.Epinephrine 55. Chemicalcardioversionisprescribedfortheclientwithatrialfibrillation.Thenursew hoisassistinginpreparingtheclientwouldexpectthatwhichmedicationspecificforchemi calcardioversionwillbeneeded? A.Nitroglycerin BNifedipine(Procardia) CLidocaine(Xylocaine) *D.Amiodarone(Cordarone) 56. Anurseassessesacomatose,headinjuredclientandfindsflexionofthearms,wrists,andfingersandadductionoftheupperextre mities.Whichofthefollowingdescribesthesefindings? A. Stroke B. EpilepticSeizure *C.Decorticateposturing D.Decerebrateposturing 57. TheclientdiagnosedwithARDSistransferredtotheintensivecaredepartmentandplac edonaventilator.Whichinterventionshouldthenurseimplementfirst? AConfirmthattheventilatorsettingsarecorrect BVerifythattheventilatoralarmsarefunctioningproperly *C.Assesstherespiratorystatusandpulseoximeterreading. DMonitortheclientsarterialbloodgasresults. 58. The low-pressure alarm sounds on aventilator. A nurse assesses the client and then attempt sto determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initialaction? A. Administeroxygen B. Checkstheclient’svitalsigns *CVentilatestheclientmanually D.Startscardiopulmonaryresuscitation 59. TheclientisadmittedtotheEDwithchesttrauma.Whichsigns/symptomswouldthe nurseexpecttoassessthatsupportsthediagnosisofpneumothorax? A.Bronchovesicularlungsoundsandfrictionrub *BAbsentbreathsoundsandtachypnea CNasalflaringandlungconsolidation DSymmetricalchestexpansionandbradypnea. 60. AnurseisplanningcareforaclientwithachesttubeattachedtoaPleurEvacdrainagesystem.Thenurseincludeswhichinterventionsintheplan?Selectallthatapp ly A. Clampingthechesttubeintermittently *B.Changingtheclient’spositionfrequently *C.Maintainingthecollectionchamberbelowtheclient’swaist *D.Addingwatertothesuctioncontrolchamberasitevaporates. *ETapingtheconnectionbetweenthechesttubeandthedrainagesystem. 61. Aclienthasatotalserumcalciumlevelof7.5mg/dl.Whichclinicalmanifestationswouldthe nurseexpecttonoteonassessmentoftheclient?Selectall AConstipation *BMuscletwitches CHypoactivebowelsounds *DHyperactivedeeptendonreflexes *EPositiveTrousseau’ssignandpositiveChvostek’ssign *F.ProlongSTintervalandQTintervalonECG 62. Theclientdiagnosedwithruleoutmyocardialinfarctionisexperiencingchestpainwhilewalkingtothebathroom.Whichactio nshouldthenurseimplementfirst? A.Administersublingualnitroglycerin. BObtainaSTATelectrocardiogram *CHavetheclientsitdownimmediatelyDAss esstheclien’ts vitalsigns. 63. ThenurseiscaringforaclientdiagnosedwithARDSwhoisonaventilator.Whichint erventionsshouldthenurseimplement.Selectall *AAssesstheclient’s levelofconsciousness *BMonitorclientsurineoutput *CPerformpassiverangeofmotionexercise *Dmaintainintravenousfluidsasordered EPlacetheclientwiththeHOBflat 64. Thenurseisassessingaclientexperiencingmotorlossasaresultofaleftsidedcerebrova scularaccident(CVA).Whichclinicalmanifestationswouldthenursedocument? ThemostcommonmotordysfunctionofaCVAisparalysisofonesideof thebody,hemiplegia;inthiscasewithaleftsidedCVA,paralysiswouldaffecttherightside.Ataxiaisanimpairedabilitytocoordinatemove ment. 65. Whenteachingaclientabouttheexpectedoutcomesafterintravenousadminis trationoffurosemide,thenursewouldincludewhichoutcome? A. Increasedbloodpressure *BIncreasedurineoutput CDecreasedpain DDecreasedPVCs 66. Aclientarrivesattheemergencydepartmentwithdeeppartialthicknessandburnsover15 %ofhisbody.Atadmissionhisvitalsignsarebloodpressure100/50mmHg,heartrate130beat s/minuteandrespiratoryrate20breaths/minute.Whichnursinginterventionareappropriate forthisclient?Selectallthatapply A.StartinganIVinfusionoflactatedRingerssolution B. Administering6mgofmorphineIV C.Administeringtetanusprophylaxisasordered 67. Ifdietarytraysareusuallybroughttothenursingunitat8:00amthenurseshouldplantoadm inisterintermediate-actinginsulin(HumlinN)40unitsSQtotheclientbetween? ANSWER-630amand700am 68. WhatECGchangeswouldreflectmyocardialischemiainaclientwhohasbeenadmitte dforobservationafterexperiencinganepisodeofchestpain? ANSWER-STsegmentelevationordepression 69. Theclientwithacuterenalfailurehasaserumpotassiumlevelof6.0mEq/L.Thenursewou ldplanwhichofthefollowingasapriorityaction? ANSWER-Placetheclientonacardiacmonitor 67. Thenurseiscaringforaclientwhounderwentcardiaccatherization1hourago.Whatisan importantnursingmeasuresatthistime? ANSWERMAINTAINPRESSUREOVERCATHETERINSERTIONSITEANDDETERMI NEDISTALCIRCULATIONSTATUS. 68. Anurseissuctioningtheendotrachealtubeofaclientwhoisonaventilator.Theclient’she artrateincreases???to110minandbecomesirregular.Thenurseshouldknowthattheclie ntrequires? ANSWER-OXYGENATEPRIORTOSUCTIONING 69. AclientcomesintotheERwithcomplainsofmidsternalchestpainradiatingtotheneckandle ftarmwhichisunrelievedbysublingualnitroglygen.Anelectrocardiogram(ECG)isobtained. WhatobservationontheECGoronthecardiacmonitorwouldindicatetothenursetheneedtoim mediatelynotifythephysician? A. PRimpulse0.20sec B. Tachycardiarateof125beatofpremature C. prematureventriclebeat D.AnSTsegmentelevationfromtheisoelectricbaseline. 70. Aclientbeginscomplainsofchillsanddiscomfortafterabout50mlofbloodhaspackedre dbloodcells.Thebestnursingactionatthistimeisto A. DiscontinuethetransfusionandmovetheIVandrestartIVtransfusionatanothersite. B. comparetheVSnowandwhattheywerebeforethetransfusionbegin C. STOPTHETRANSFUSIONANDMAINTAINAPATENTLINEWITHNORMAL SALINEsolutionandnewtubing D.slowdownthetransfusionbloodanddilutewithnormalsalinesolution 71. Thevitalsignsofaclientwithcardiacdiseaseareasfollowsbloodpressureof103/78m mHg,heartrate???beats/min,andrespiratoryrateof16breaths/min.Atropine(atropine? ???AdministeredIVpush.Whatnursingassessmentindicatesatherapeuticresponsetothe medication? ANSWER-Pulseratehasincreasedto70beats/min 72. Orderrocephen1gover30minutesQ6H.Supply1g/100mL.HowmanymLperhourwil lthenurseinfuse?Roundthenearestwholenumber. ANSWER-200ml/hr 73. Thenurseiscaringforclientwhois1daypostoperativefollowinganopenthoracotomy .Theclientisreceivingoxygenmistat40percent.The02saturation measuredbypulseoximeterwas83ABGresultsarepH7.31,PACO293mmHg,HCO325m eq/L.Whichofthefollowingisanappropriateactionbythenurse? ANSWER-POSITIONCLIENTINHIGHFOWLERSANDENCOURAGEUSEOFINCENTIVESPIROMETERANDCOUGH ING. 74. ThediabeticeducatoristeachingaclassonDiabetesType1andisdiscussingsickdayr ules.Whichinterventionsshouldthediabetescounselorincludeintheteaching?Selectall thatapply ANSWERA)Takediabeticmedicationevenifunabletoeattheclient’snormaldiet. B)Ifunabletoeat,drinkliquidsequaltotheclient’snormaldiet. D)Testthebloodglucoselevelsandtesttheurineketonesonceadayandkeepareco rd. 75. Thenurseismonitoringaclientreceivingpertionaldialysisnotesthattheclient’s outflowislessthaninflow.Whatactionshouldthenursetake?Selectallthatapply? ANSWER-(SELECT ALL ANSWERS EXPCEPT–CONTACT THE HEALTH CARE PROVIDER & INCREASE THEFLOW -DONOTSELECTTHOSETWOANSWERS) 76. Thenurseisobtainingahealthhistoryfromaclientwhoisvisitingtheclinicwithcomplaints ofasevereheadache.Theclientprovidesthefollowingdatatothenursebasedonareviewofsyst ems.Thenurseidentifiesthefollowingasamodifiableriskforstroke?Selectalltheapply. A.SMOKING B. ALCOHOLCONSUMPTION C.DECREASEDPHYSICALACTIVITY D. OBESITY 77. ThenurseiscaringforaclientdiagnosedwithARDSwhoisonaventilator.Whichint erventionshouldthenurseimplement?Selectallthatapply A.Assesstheclient’slevelofconsciousness. B. Monitortheclient’surineoutput C.Performpassiverangeofmotion(ROM)exercise. D.Maintainintravenousfluidsasordered. 78. Thenurseisperforminganassessmentonaclientwhohasreturnedfromdialysisunitfollo winghemodialysis.Theclientiscomplainingofheadache,nausea, andisextremelyrestless.Whichofthefollowing??themostappropriatenursingaction? ANSWER-NOTIFYTHEPHYSICANS 79. Thenursedeterminesthataclientwithdiabetesmellitusisexperiencingfatbreakdownforconversiontoglucoseiftheclienthaselevatedl evelsofwhichsubstanceintheurine? ANSWER-ketones 80. TheclientisadmittedtheEDwithchesttrauma.Whichsignsandsymptomswouldthe nurseexpecttoassessthatsupportsthediagnosisofpneumothorax? ANSWER-ABSENTBREATHSSOUNDSTACHYPNEA 81. Thenurseiscaringforhospitalizedclients.Whichofthefollowingclientsisatgreatestr iskforfluidvolumedeficit? ANSWER-THECLIENTWHOHASJUSTBEENADMITTEDHASSEVERE DIARRHEAANDISfebrile. 82. PT&INRforCoumadin,INR2.8:continuemedication 83. Hotspot:apicalpulse 84. Hotspot:Twave 85. Hotspot:Pwave 86. Pwave:atrialdepolarization 87. Assessingresponseinanunconsciouspatient:nailbedpressure(peripheral) 88. HbA1cconsiderationsforabout3monthsofglucosemonitoring a. lessthan6%fornondiabetic b. diabeticcontrolledshouldbelessthan7% 89. Sengstaken-Blakemoretubepreventsbleeding(esophagealvarices) a. Triplelumen b. Havescissorsatthebedside c. Provideoralandnasalcareevery3hours d. Usedtoreducebleeding 90. Planningrehabilitationforastrokepatient a. Assessfunctionalstatusbeforedevelopingplan i. Walking,speaking,eating,ADLs 91. CranialnerveII:Snellentest 92. T2-T3:Paraplegia 93. ICP:nolumbarpuncture 94. Anurseobservingaclosechesttubedrainagesystemispostop1daythoracot omy?Continuebubblinginthesuctionchamber? A. checkthecontroloutletagainstthewall B. observealltheconnectiontubing C. Continuetomonitorclientrespiratorystatus D.NotifyMDoftheoxidation 95. Aclientadmittohospitalreportrecurrentflankpain,nausea,andvomitingwithin24 hours.Whichofthefollowingprioritynursingaction? A. Administeredpainmedication B. Monitorintakeandoutput C. Administeredantiemetics D. Strainurine 96. Anurseiscaringforclientwhohavetype1DM.Thenursemisreadclientmorningbloodgluc oselevelat210mg/dLinsteadof120mg/dLbaseonthiserror.Sheadmittedinsulindoseof200m g/dLbeforeclientbreakfast.Whichofthenursingpriority? Monitorclientforhypoglycemia 97. AAnurseiscaringaclientwhoisscheduleofcolonoscopy.Theclientaskthenurseif therewillbealotofpainduringprocedure.Whichofthefollowingisappropriatenursi ngresponse? A. No,youshouldn’tfeelanypainbecauseyourrectumwillbeanesthesia B. Youmaybesedatedbutyouwillfeeldiscomfortduringtheinstrumentinsertion C. Don’tworry?? D. ??? 98. AAnurseisperformingteachingforclientwhohaverecentlydiagnosistype2DM.nurseshoul drecognizethattheclientunderstoodtheteaching.Identifyhypoglycemia?Selectall A. Moist,clammyskin B. Tachycardia C. Polyuria D. Polydipsia E. Polyphagia F.??? 99. Anurseadmittedmorphine2mgIVpushafterclientreportpainandevaluateclient15mi injection.Whichfollowadverseeffect? A.painscalelevelof6to4 B.sleepybutarousewhennamecall C.O2sat94% D.RR8bpm 100. Anurseassessaclientwho8scoreusingtheGlasgowcomascaletoelevateofconsciou sness.Describethescore. A. Reflexalertclient B. Needoftotalnursingcaring C. Clientindeepcoma D. Stableneurologicalstatus 101. clientlowsodiumdietandreducefluidintaketochooselunch. A. Tunasandwichonwheatbread,canofcocktailfruit,salad,andsoda B. Grillchickensandwichonwhitebread,apple,salad,andicetea C. Grillcheesesandwich,tomatosoup D. Hamandbean 102. clientacuteMI.acardiacenzymeobtain.Cardiacenzymeidentify? A. damagetothemyocardial B. determinethesizeMI C.helptodeterminethelocationMI D.???? isteredDDAVPtoclientdiagnosisDI.Therapeuticeffect 1. Specificgravity(1.015)