ATI MED SURG PROCTORED NGN RETAKE ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS.

ATI MED SURG PROCTORED NGN RETAKE ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? Hgb 8.2 g/dl. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? Desmopressin. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? Stool for occult blood - GI bleed. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Initiate airborne precautions. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? Transmucosal fentanyl. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? ST segment. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? Pat the skin on the radiation site to dry it. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? Furosemide. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? Apical pulse 82/min. A nurse is reviewing a client's ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? Compensated respiratory alkalosis. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours Hypoalbuminemia (Low due to fluid loss). A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? Have the client lie down for 30 minutes after meals. (Lying down after a meal slows the movement of food within the intestines) A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? Administer the plasma immediately after thawing. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? Hypocalcemia. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? Use a 10-milliliter syringe when flushing the catheter. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? WBC count of 16,000/ mm. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? I will spread my protein allowances over the entire day. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? Verify the placement with an x-ray prior to the initial dose. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? Exhale fully before bringing the inhaler to your lips. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? A client who has pancreatitis reports pain in the left shoulder. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? The client's capillary refill in the left toe is 6 seconds. (signs and symptoms of compartment syndrome) A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to intervene? Crackle in bilateral lower lobes. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? Feet elevated. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make? "This is an expected adverse effect of this medication." A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? Begin an IV infusion of 0.9% sodium chloride. A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? Assess urine output hourly ---à prevent shock and mods. 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and to stop patient on urinating. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? Ibuprofen –NSAIDs. 1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? c. Hgb 8.2 g/dl Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. A nurse is assessing the extremities of a client who has Raynaud's disease. Which of the following findings should the nurse expect? Blanching of the hands REYNAUD PHENOMENON. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? A client who has a right upper extremity arteriovenous fistula. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? Oral Contraceptive Use. A nurse is caring for client who has Cushing's disease. Which of the following actions should the nurse take first? (Click Exhibit button for additional information) Auscultate the client's lung sound - due to fluid retention; action first varies on the exhibit. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? Proteinuria. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? Pitting edema. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? Vigorously strip the chest tube twice daily. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure? Monitor Intake and Output. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? I need to check my pulse rate every day for a full minute. A nurse in a clinic is providing preventive teaching to an older adult client during well visit. The nurse should instruct the client that which of the following immunization are recommended for healthy adults after age 60? Select all the Apply. Herpes Zoster Influenza Pneumococcal Polysaccharide. A nurse is assessing a client who is 4hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report immediately? Pallor in the affected extremity. A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? Diminished peripheral pulses. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? May operate a motor vehicle when no longer taking analgesics. A nurse is assessing for elderly signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect? Intense pain with movement. A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later. Which of the following lab findings indicates a positive response to the oxygen therapy? PaO2 90 mmHg. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear (VIII)? Disequilibrium with movement. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? Glasgow coma scale score changes from 14 to 9. A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of the following should the nurse assess first? Cardiovascular status dysrhythmia due to potassium. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? Ask the client to empty his bladder prior to the procedure. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolytes imbalances? Hypocalcemia. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC's. Which of the following findings is an indication of a hemolytic transfusion reaction? Hypotension. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? Administer atropine to the client. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted central catheter. Which of the following actions should the nurse take? Place a dry sterile dressing to the site after removal. A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? Provide humidified oxygen. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the following manifestations should the nurse include in the teaching? Hypoxemia. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Lower the client to the floor (ATI video says this if standing). A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing change. Which of the following instructions should the nurse include in the teaching? Wear a mask during dressing change. A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr. ago. Which of the following findings should the nurse expect? Hypotension. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? Mental confusion. A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching? I rest in my recliner with my feet elevated for about an hour every afternoon. A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis. Which of the following instructions should the nurse include in the teaching? Sit upright for 30 min after taking the medication. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? Administer IV fluids to the client. A nurse is completing an assessment of an older adult client and notes redness areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows. A nurse is caring for a client who has completed 10 daily cycles of Total Parenteral Nutrition (TPN). Which of the following findings indicates that the client is receiving adequate TPN supplementation. Weight gain of 9.1 kilograms to 20 pounds. A nurse is providing teaching to a client who is post-operative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? I will rinse my toothbrush with hydrogen peroxide and water after each use. A nurse is performing ear irrigation for a client. Which of the following actions should the nurse take? Point the tip of the syringe toward the top of the ear canal. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? Check the client's urine output. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? I will draw up regular insulin into the syringe first. A nurse is caring for a client who is receiving Total Parenteral Nutrition (TPN). Which of the following nursing actions are appropriate? (Select all the apply) Obtain the client's weight daily Monitor serum blood glucose during infusion- A nurse is caring for a client in diabetic ketoacidosis DKA. Which of the following is the priority intervention by the nurse? Administer 0.9% sodium chloride. A nurse is reviewing the laboratory results of a female client who asked about acupuncture treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results contraindication to receiving acupuncture? Absolute neutrophil count 5000/mm3. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a Pain Scale of 0 to 10. Which of the following should the nurse take? Apply and ice pack to the client's knee. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? Muscle weakness. A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has recall memory impairment? Inability to state what he has for dinner last night. A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? Mannitol. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First? A client who has thrombocytopenia and reports and nosebleed. A home care nurse is planning to use non-pharmacological pain relief measures for an older client who has severe chronic back pain. Which of the following guidelines should the nurse use? Distraction changes the client's perception of pain but does not affect the cause. A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal drainage system. Which of the following actions should the nurse take? Refill the water chamber if the fluid is low. A nurse is in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block? Prolonged PR intervals. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. Obtain the unit of packed RBCs from Blood Bank 1 Verify blood compatibility with another nurse 2 Obtain venous access using a 19-gauge needle 3 Initiate transfusion of the unit of packed RBC's 4 Remain with the client for the first 15 to 30 minutes of the infusion 5 A nurse is teaching a client who is to begin chemotherapy about peripherally inserted central catheter. Which of the following statements should the nurse include in the teaching? We can draw blood samples from the PICC for diagnostic test. A nurse is assessing a client who has Pyelonephritis and reports flank pain. Which of the following actions should the nurse take? Assist the client to a sitting position. A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider? Weight gain 1.1 kilogram to 2.4 pound in 24-hour. A nurse is caring for an older adult client who is 72 hours postoperative following a total hip arthroplasty. The client requires a PRN medication prior to ambulation. Which of the following medications should the nurse anticipate administering? Oxycodone Oxycontin Opioids agent. A nurse is caring for a client who has Haemophiles Influenzae type B. which of the following types of isolation should the nurse implement? Droplet. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include, as an indication the client is no longer infectious? Negative sputum culture for acid fast bacillus. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's Airway which of the following interventions should the nurse take first? Start an IV with a large bore needle. A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? Clamp the catheter. A nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? Wash your perineal area 2 times each day with antimicrobial soap. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? Serum Ammonia. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? The client's abdomen becomes distended and firm. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? I have a nagging, dry cough. A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? Observe for symmetry of chest expansion. A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? Drink 2 to 3 L of fluid daily. A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take? Apply a cooling blanket. A nurse is presenting an in-service program about Parkinson's disease (PD). Which of the following statements should the nurse include in the teaching? PD results from a decreased amount of dopamine in the client's brain. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? Thrombocytopenia. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are testing on the floor. Which of the following actions should the nurse take? Pull the client up in bed. A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in which of the following laboratory results? Uric acid. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? "I'm going to include more cantaloupe in my diet." 3. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? b. Stool for occult blood - GI bleed. Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abdominal pain). 4. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) c. Initiate airborne precautions. 5. A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate? a. Transmucosal fentanyl. Rationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. A short-acting pain medication is administered for breakthrough pain. 6. A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction? d. ST segment. Rationale: ST elevation indicates MI. ST depression indicates ischemia. 7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include? a. Pat the skin on the radiation site to dry it Rationale: pg. 584. Dry the area thoroughly using patting motions. 8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? d. Furosemide Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent cardiovascular/respiratory distress. 9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia. Which of the following findings indicates effectiveness of the medication? b. Apical pulse 82/min. 10. A nurse is reviewing a client's ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize these findings as indication of which of the following conditions? c. Compensated respiratory alkalosis. Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis. 11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs should the nurse expect during the first 24 hours C. Hypoalbuminemia (Low due to fluid loss) 12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should the nurse takes? d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food within the intestines) Rationale: ATI pg. 318 Dumping syndromes is a term that refers to a constellation of vasomotor symptoms that occurs after eating. to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. 12. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (SATA) b. Chronic infections of the middle ear c. Use a loop diuretic-such as furosemide and antibiotics like aminoglycoside and gentamicin leads to ototoxic medication d. Perforation of the eardrum 13. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? a. Administer the plasma immediately after thawing. 14. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect? Hypocalcemia. 15. A home health nurse is teaching a client how to care for a peripherally central catheter in his right arm. Which of the following statements should the nurse include in the teaching? d. Use a 10-mLsyringe when flushing the catheter. A nurse is providing dietary teaching to a client who has chronic kidney disease and a decreased glomerular filtration rate. Which of the following statements by the client indicates an understanding of the teaching? a. I will spread my protein allowances over the entire day. 16. A nurse is caring for a client who has a central venous access device. Which of the following assessment findings should the nurse report to the provider? c. WBC count of 16,000 18. A nurse is caring for a client who has a peripherally inserted central catheter. The client is receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse take? c. Verify the placement with an x-ray prior to the initial dose (POSTPROCEDURE). 19. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following statements should the nurse include in the teaching? b. Exhale fully before bringing the inhaler to your lips. 20. A nurse is assessing the pain status of a group of clients. Which of the following findings indicate a client is experiencing referred pain? b. A client who has pancreatitis reports pain in the left shoulder- referred pain is pain that is felt in another. 21. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessments findings requires immediate intervention by the nurse? b. The client's capillary refill in the left toe is 6 seconds (signs and symptoms of compartment syndrome) 23. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? d. Feet elevated (Trendelenburg) 24. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make? c.) "This is an expected adverse effect of this medication." 25. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse take? c.) Begin an IV infusion of 0.9% sodium chloride. 26. A nurse is planning care for a client who is 12 hr. postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? c.) Assess urine output hourly - 30ml/hr, report; prevent shock and mods 28. A nurse is obtaining a medication history from a client who is to start therapy with naproxen for rheumatoid arthritis. Which of the following medications places the client at risk for bleeding? b.) Ibuprofen --NSAIDs 30. A nurse is assessing the extremities of a client who has Raynaud's disease. Which of the following findings should the nurse expect? Blanching of the hands REYNAUD PHENOMENON. 31. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients? A client who has a right upper extremity arteriovenous fistula. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? b. Chronic infections of the middle ear c. Use a loop diuretic such as furosemide and antibiotics like aminoglycoside and gentamicin leads to ototoxic medication d. Perforation of the eardrum 32. A nurse is providing teaching to a client who has DVT. Which of the following findings should the nurse identify as a risk factor for the development of DVTs? d. Oral Contraceptive Use 33. A nurse is caring for client who has Cushing's disease. Which of the following actions should the nurse take first? (Click Exhibit button for additional information) Auscultate the client's lung sound - due to fluid retention; action first varies on the exhibit 34. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the nurse expect? a. Proteinuria Rationale: Lewis book page 1075. Clinical manifestation of N.S.: peripheral edema, massive proteinuria, HTN, hyperlipidemia, and hypoalbuminemia. 35. A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find? d. Pitting edema 36. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? c. Vigorously strip the chest tube twice daily. (Vigorously and BID) Rationale: Page 104 chapter 18 of ATI Book it says that: "Do not strip or milk tubing; only perform when prescribed. Stripping creates a high negative pressure and can damage lung tissue. Stripping tube of clots 37. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the following instructions should the nurse include for home management of heart failure? c. Monitor Intake and Output 38. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? b. I need to check my pulse rate every day for a full minute. 39. A nurse in a clinic is providing preventive teaching to an older adult client during well visit. The nurse should instruct the client that which of the following immunization are recommended for healthy adults after age 60? Select all the Apply. a. Herpes Zoster b. Influenza e. Pneumococcal Polysaccharide 40. A nurse is assessing a client who is 4hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report immediately? b. Pallor in the affected extremity 41. A nurse is caring for an older adult client who has not been eating. Which of the following findings indicates dehydration? c. Diminished peripheral pulses 42. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? b. May operate a motor vehicle when no longer taking analgesics 43. A nurse is assessing for late signs of compartment syndrome for a client who has a short leg fiberglass cast. Which of the following findings should the nurse expect? d. Intense pain with movement 44. A nurse is caring for a client who is postoperative following coronary artery bypass surgery and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later. Which of the following lab findings indicates a positive response to the oxygen therapy? c. PaO2 90 mmHg (Normal range: 80-100 mmHg) 45. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear (VIII)? b. Disequilibrium with movement- (Positive Romberg) 46. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a. Glasgow coma scale score changes from 14 to 9 48. A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of the following should the nurse assess first? c. Cardiovascular status- dysrhythmia due to potassium Rationale: Potassium imbalances cause dysrhythmias, which are the number one reason why potassium levels, are crucial to monitor. Hypokalemia causes ST depression, T wave depression, and elevation of U wave, which is vital for regulating normal electrical activity of the heart. Decreased extracellular potassium causes myocardial hyper excitability with the potential to develop re-entrant arrhythmias. 49. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? c. Ask the client to empty his bladder prior to the procedure 50. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolytes imbalances? D Hypocalcemia Rationale: (Parathyroid gland, which is the gland that secretes calcitonin, is right behind the thyroid. When you have a thyroidectomy, you decrease the production of calcitonin, which decreases production of calcium.) 51. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC's. Which of the following findings is an indication of a hemolytic transfusion reaction? A: Hypotension 52. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? C. Measure the client's blood pressure. Rational: TX for bradycardia: IDEA: Isoproterenol, Dopamine, Epinephrine, Atropine (first check if symptomatic) Additional source is on pg. 275 ATI Pharm; pg. 171 ATI MS 53. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted central catheter. Which of the following actions should the nurse take? D. Place a dry sterile dressing to the site after removal Rationale: Textbook pg. 132. Removal of CVADs. Immediately apply pressure to the site with sterile gauze to prevent air from entering and to control bleeding. Inspect the catheter to determine that it is intact. After bleeding has stopped, apply an antiseptic ointment and sterile dressing to the site. 55. A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? a. Provide humidified oxygen 56. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the following manifestations should the nurse include in the teaching? A. Hypoxemia 57. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? D. Lower the client to the floor (ATI video says this if standing) 58. A nurse is teaching a client who is receiving total parenteral nutrition at home through a central venous access device about transparent dressing change. Which of the following instructions should the nurse include in the teaching? C. Use clean technique when changing the dressing A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr. ago. Which of the following findings should the nurse expect? B. Hypotension Rationale: During a major burn, the initial phase will activate the Sympathetic nervous system. Hypovolemia and shock can result from fluid shifts from the intercellular and intravascular space to the interstitial space. Additional findings include hypotension, tachycardia, and decreased cardiac output. 60. A nurse in an emergency department is assessing a client who has cirrhosis of the liver. Which of the following is a priority finding? C. Mental confusion- may lead to portal systemic encephalopathy; neuro is deteriorating. 61. A nurse is providing instructions about foot care for a client who has a peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching? D. "I rest in my recliner with my feet elevated for about an hour every afternoon" Rationale: Tell the client to never apply direct heat, such as a heating pad, to the affected extremity because sensitivity is decreased, and this can cause a burn. Tell the client to elevate the legs to reduce swelling, but not to elevate them above the level of the heart because extreme elevation slows arterial blood flow to the feet. 62. A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis. Which of the following instructions should the nurse include in the teaching? Sit upright for 30 min after taking the medication (No lying down) 64. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? D. Administer IV fluids to the client Rationale: IV Bolus; Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound 65. A nurse is completing an assessment of an older adult client and notes redness areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? Support bony prominences with pillows 66. A nurse is caring for a client who has completed 10 daily cycles of Total Parenteral Nutrition (TPN). Which of the following findings indicates that the client is receiving adequate TPN supplementation. B. Weight gain of 9.1 kilograms to 20 pounds Rationale: Confirmed (TPNs are intended for patients who are malnourished so gaining 2 pounds in 2 days is good.) 68. A nurse is providing teaching to a client who is post-operative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? c. I will rinse my toothbrush with hydrogen peroxide and water after each use 69. A nurse is performing ear irrigation for a client. Which of the following actions should the nurse take? Point the tip of the syringe toward the top of the ear canal 70. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? Check the client's urine output 71. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? I will draw up regular insulin into the syringe first 74. A nurse is caring for a client who is receiving Total Parenteral Nutrition (TPN). Which of the following nursing actions are appropriate? (Select all tterm-67he apply) a. Obtain the client's weight daily c. Monitor serum blood glucose during infusion- book says check glucose level every 4 -6 hours for at least 24 hours e. Verify the solution with another RN prior to infusion 75. A nurse is caring for a client in diabetic ketoacidosis DKA. Which of the following is the priority intervention by the nurse? Administer 0.9% sodium chloride 76. A nurse is reviewing the laboratory results of a female client who asked about acupuncture treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory results contraindication to receiving acupuncture? Absolute neutrophil count 5000/mm3 77. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a Pain Scale of 0 to 10. Which of the following should the nurse take? Apply and ice pack to the client's knee 78. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? muscle weakness 79. A nurse at a long-term care facility is assessing an older adult client. Which of the following findings should the nurse identify as an indication that the client has recall memory impairment? Inability to state what he has for dinner last night 80. A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? Mannitol 81. A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to First? a. A client who has thrombocytopenia and reports and nosebleed 82. A home care nurse is planning to use non-pharmacological pain relief measures for an older client who has severe chronic back pain. Which of the following guidelines should the nurse use? Distraction changes the client's perception of pain but does not affect the cause 89. A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal drainage system. Which of the following actions should the nurse take? Refill the water chamber if the fluid is low 90. A nurse is in an emergency department is reviewing a client's ECG reading. Which of the following findings should the nurse identify as an indication that the client has first-degree heart block? Prolonged PR intervals 91. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. a. Obtain venous access using a 19-gauge needle 3 b. Obtain the unit of packed RBCs from Blood Bank 1 c. Verify blood compatibility with another nurse 2 d. Initiate transfusion of the unit of packed RBC's 4 e. Remain with the client for the first 15 to 30 minutes of the infusion 5 B, C, A, D, E 92. A nurse is teaching a client who is to begin chemotherapy about peripherally inserted central catheter. Which of the following statements should the nurse include in the teaching? We can draw blood samples from the PICC for diagnostic test 93. A nurse is assessing a client who has Pyelonephritis and reports flank pain. Which of the following actions should the nurse take? Assist the client to a sitting position (comfort by relieving pressure) 94. A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider? Weight gain 1.1 kilogram to 2.4 pound in 24-hour 95. A nurse is caring for an older adult client who is 72 hours postoperative following a total hip arthroplasty. The client requires a PRN medication prior to ambulation. Which of the following medications should the nurse anticipate administering? d. Oxycodone Oxycontin Opioids agent. 96. A nurse is caring for a client who has Haemophiles Influenzae type B. which of the following types of isolation should the nurse implement? droplet 97. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include, as an indication the client is no longer infectious? Negative sputum culture for acid fast bacillus 98. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's Airway which of the following interventions should the nurse take first? Start an IV with a large bore needle Rationale: To maintain cardiac output, maintains tissue perfusion, and prevent hypovolemic shock. Initiate IV access using a large bore needle. If burns cover a large area of the body, the client requires insertion of central venous catheter or IO. Fluid replacement is important during the first 24 HR. 99. A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? Clamp the catheter. Rationale: a pressure change during tubing changes can lead to an air embolism. Clamp the catheter immediately and place the client on his left side in Trendelenburg position to trap air. 100.A nurse is providing discharge teaching to a client who has impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching? Wash your perineal area 2 times each day with antimicrobial soap 101. A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing the client? Serum Ammonia 102. A nurse is caring for a client who has admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? The client's abdomen becomes distended and firm 103. A nurse is caring for a client who takes Lisinopril for HTN. Which of the following client statements indicates an adverse effect of the medication? I have a nagging, dry cough 104. A nurse is caring for a client who has an endotracheal tube. Which of the following actions should the nurse take to verify tube placement? Observe for symmetry of chest expansion 105. A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? Drink 2 to 3 L of fluid daily 106. A nurse is caring for a client who presents to the emergency department after experiencing a heat stroke. Which of the following actions should the nurse take? a. Apply a cooling blanket. 107. A nurse is presenting an in-service program about Parkinson's disease (PD). Which of the following statements should the nurse include in the teaching? PD results from a decreased amount of dopamine in the client's brain 108. A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? Thrombocytopenia 109. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take? Pull the client up in bed 110. A nurse is reviewing a medical record of a client who has acute gout. The nurse expects an increase in which of the following laboratory results? Uric acid 111. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? "I'm going to include more cantaloupe in my diet." A nurse at a provider’s office is caring for an older adult client who is having an annual physical exam. Which of the following findings indicates additional follow-up is needed in regard to the prostate gland? (Select all that apply.) A. Prostate specific antigen (PSA) is 7.1 ng/mL. B. A digital rectal exam (DRE) reveals an enlarged and nodular prostate. C. The client reports a weak urine stream. A nurse is providing information to a client who is scheduled for a transrectal ultrasound (TRUS). Which of the following information should the nurse include? C. "Sound waves will be used to create a picture of your prostate." A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? D. Provide a high-calorie and high-carbohydrate diet. A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following laboratory findings should the nurse expect? B. Positive EIA test A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply.) B. Change in orientation C. Asterixis E. Fetor hepaticus A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.) A. Diuretic B. Beta-blocking agent D. Lactulose A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Limit physical activity. B. Avoid alcohol. E. Eat small frequent meals. A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? D. Bronchitis 2 weeks ago A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse is appropriate? A. Check continuous passive motion device settings. B. Palpate dorsal pedal pulses. D. Elevate heels off bed. A nurse is planning a discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Clean the incision daily with soap and water. C. Sit in a straight-backed armchair. E. Use a raised toilet seat. A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply.) B. Pain when bearing weight C. Joint crepitus D. Swelling of affected joint E. Limited joint motion A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.) A. Encourage complete autologous blood donation. D. Use an abductor pillow when turning the client. E. Perform isometric exercises. A nurse is preparing to administer an IM injection of immune globulin to a client who has been exposed to hepatitis A. Which of the following statements by the nurse is appropriate? C. "This medication provides you with an immune response more quickly than your body can produce it." A nurse is preparing to administer a varicella immunization to a client. Which of the following questions by the nurse is appropriate? C. "Are you pregnant?" A nurse is reviewing strategies to promote comfort with a client who received an immunization. Which of the following information should the nurse include? B. Apply a cool compress to the injection site. C. Take acetaminophen or ibuprofen. D. Use the affected extremity. A nurse is preparing to document administration of a meningococcal vaccine to a client. Which of the following information should the nurse include in the documentation? (Select all that apply.) B. Name of the vaccine manufacturer C. Vaccine expiration date D. Date of administration A nurse in a clinic is caring for a client who is to receive an immunization. The client asks about contraindications to immunizations. Which of the following is an appropriate response by the nurse? D. "Your provider will weigh the risks if you have experienced any adverse reactions." A nurse is caring for a client who has a serum sodium level 133 mEq/L and serum potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? A. Three tap water enemas A nurse is caring for a client who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations? A. ECG changes A nurse is caring for a client who has a nasogastric tube attached to a low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? Hyponatremia A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. Diabetic ketoacidosis A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? C. Tap lightly on the client's cheek. A nurse is preparing to administer packed RBCs to a client who has Hgb of 8 g/dL. Which of the following actions should the nurse to take during the first 15 min of the transfusion? B. Assess for an acute hemolytic reaction. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. C. Maintain an IV infusion with 0.9% sodium chloride. E. Administer diphenhydramine. A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) C. Heart rate change from 88/min pretransfusion to 120/min E. Client appears flushed A nurse is providing a preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? C. "You can donate blood each week if your hemoglobin is stable." A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? D. Obtains vital signs every 15 min throughout the procedure. A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? Intense pain with movement A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? Back pain A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? Place two bed pillows between the legs when in bed A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances? Latex A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? Hold breaths about 3 to 5 seconds before exhaling A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? Initiate cardiac monitoring for the clients A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? Hang the drainage bag below the client's abdomen A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? Disequilibrium with movement A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? Apply compression stockings to the lower extremities A nurse is caring for a male client who has an exacerbation of heart failure. Which of the following prescriptions should the nurse expect to receive from the provider? (Click on the "exhibit" button for additional information about the client. There are 3 tabs that contain separate categories of data.) Atropine 1mg IV bolus every 5 min up to 3 mg A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? I should expect less than 25 L of secretions per day in the drainage devices A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching? Exhale fully before bringing the inhaler to your lips A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider? Calcium level 11.5 mg/dL A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? May operate a motor vehicle when no longer taking analgesics A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.) Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap Select a work surface at the nurse's waist level A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? Obtain consent for surgery A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? Altered level of consciousness A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma? Flat lesion with irregular borders A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? Desmopressin A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take? Confirm the correct position of the line by obtaining a blood sample A nurse is caring for a client who had an arterial revascularization of the lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) 1. Increase the insulin rate per protocol. ??? 2. Increase the heparin infusion rate per protocol. 3. Change the PCA timing of the patient control bolus to every 15 min. 4. Start an IV fluid bolus of 0.9% sodium chloride 500mL to infuse over 1hr A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? Drink 2 to 3 L of fluids daily A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? Describe your daily medication schedule A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first? Stop the infusion. A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse? Administer a sedative medication A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? Instruct the client to avoid eating raw fruit. A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? Hemoglobin 10 mg/dL A nurse is caring for a client who was admitted with nausea, vomiting, and possible bowel obstruction. An Ng tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? The client's abdomen becomes distended and firm. A nurse is reviewing the medical record of a client who is scheduled for a CT scan with a contrast media. Which of the following medications should the nurse instruct the client to withhold for 48hr following the procedure? Metformin A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? Instill 0.9% sodium chloride solution into the affected eye. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? I apply a lubricating lotion to the cracked areas on the soles of my feet every morning A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis? "Do you have any household pets, such as a cat?" A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? Confusion A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes? To provide positive airway pressure during inspiration A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? High-pitched sound on inspiration A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? A client who has thrombocytopenia and reports a nosebleed A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider? Vigorously strip the chest tube twice daily A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care? Palpate the site for a thrill A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral? The client has a prescription for long term IV antibiotic therapy A nurse is caring for a client who is 6 hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? Palpate the dorsalis pedis pulse A nurse is providing teachin