Med Surg: Final, Comprehensive predictor test 85
Answer, ATI comprehensive predictor STUDY THIS ONE,
NUR325 Exam 1 ASU - ATI, Textbook Questions, NCLEX
challenge 8, ATI comprehensive, PN comprehensive
predictor practice B
A nurse is reviewing the laboratory findings of a client who had a myocardial infarction
6hr ago. Which of the following is an expected finding for this client? - CORRECT
ANSWER Troponin I 8ng/mL
- This value is above the expected reference range for Troponin I and is a specific
marker of MI.
A nurse is caring for a client who is having a febrile reaction while receiving a blood
transfusion. The nurse should administer which of the following medications? -
ANSWER Acetaminophen
- The nurse should plan to administer an antipyretic such as acetaminophen for a febrile
reaction to a blood transfusion.
Diphenhydramine for a mild allergic reaction.
Furosemide, a loop diuretic, for circulatory overload.
IV antibiotic such as cephalexin for sepsis due to receiving contaminated blood from a
transfusion.
A nurse is providing teaching for a client who has a gastric ulcer and a new prescription
for omeprazole. The nurse should instruct the client that the medication provides relief
by which of the following actions? - ANSWER Suppressing gastric acid production.
- Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric ulcers by
suppressing gastric acid production.
A nurse is administering meperidine IM in the right deltoid of a client. The nurse
aspirates and pulls back blood in the syringe. Which of the following action should the
nurse take? - ANSWER Dispose of the medication.
- The presence of blood indicate improper placement of the needle, and the solution
and needle are now contaminated. The nurse should dispose of the medication
,according to facility protocol, and obtain a new dose of medication, syringe, and needle.
A nurse is caring for a client who has COPD and is receiving nebulizer treatments of
acetylcysteine. Which of the following client statements indicates the medication is
effective? - ANSWER "I can cough up my secretions more easily now."
- Acetylcysteine thins pulmonary secretions, which increases the client's ability to cough
up secretions.
A nurse is caring for a client who has a Stage III pressure ulcer. Which of the following
should the nurse use when changing the client's dressing? - ANSWER
Hydrocolloid dressing.
- The nurse should use a hydrocolloid dressing to keep the wound bed moist.
Adhesive transparent film is used over intact skin.
Nonadherent gauze dressing is for a wound that has little to no drainage.
Wet to damp dressing is for mechanical debridement.
A nurse is reviewing the ABG values of a client who has COPD. The client's laboratory
values are pH 7.31, PaCO2 68mmHg, CO3- 26mEq/L, and PaO2 75mmHg. Which of
the following findings should the nurse expect? - ANSWER Kussmaul respirations.
- The client's ABG values indicate respiratory acidosis with manifestations of Kussmaul
respirations.
Hyperreflexia, hypertension, or tetany are expected findings in a client who has
respiratory alkalosis.
A nurse is caring for a client who has a cervical spinal cord injury sustained 1month
ago. Which of the following manifestations indicates the client is experiencing
autonomic dysreflexia? - ANSWER Heart rate 52/min
- Bradycardia is a manifestation of autonomic dysreflexia.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory findings to be below the expected reference range? - CORRECT
ANSWER Serum calcium
- A client who has pancreatitis will have decreased serum calcium due to fat necrosis.
A client presents to the clinic for a 1 week follow up visit after hospitalization for heart
failure. Based on the information in the chart, which of the following findings should the
nurse report to the provider? - ANSWER Heart rate 55/min
- This heart rate is a significant drop from baseline, and it can indicate the development
,of digoxin toxicity.
A client has a prescription for total parenteral nutrition at a rate of 3L/24hr. The
prescription calls for a 50% infusion rate for the first 24hr. The nurse should recognize
that the client will receive how may milliliters in the first 48hr? - ANSWER 4,500
- The client is receive 3,000mL per 24hr, but only half that amount for the first 24hr. So,
the client would receive 1,500mL in the first 24hr and the full 3,000mL in the second
24hr, for a total of 4,500mL for the first 48hr.
A nurse is caring for a client who has increased intracranial pressure (ICP) and received
mannitol. The nurse recognizes which of the following is an adverse effect of this
medication that should be reported to the provider? - ANSWER Headache
- Headache is an adverse effect of this medication. The nurse should notify the provider
immediately as this may indicate that the client is experiencing a rebound increase in
ICP.
A nurse is caring for a client who has biliary colic. Which of the following should the
nurse administer? - ANSWER Hydromorphone
- The nurse should administer hydromorphone to manage the client's pain caused by
biliary colic.
A nurse is assessing a client who has a stage 2 pressure ulcer. Which of the following
findings should the nurse recognize as a sign that the ulcer is healing? - CORRECT
ANSWER Moist, bright red surface in the wound bed.
- A moist, bright red wound bed indicates healing is taking place.
Erythema surrounding the wound indicates inflammation and irritation.
Brown, denatured collagen indicates necrotic tissue.
Dry, hard tissue indicates poor local arterial blood supply and lack of healing.
A nurse is assessing a client who has hypokalemia. Which of the following clinical
manifestations should the nurse expect? - ANSWER Decreased peristalsis
- Decreased peristalsis is a clinical manifestation of hypokalemia.
Facial twitching and hyperreflexia are clinical manifestations of hyperkalemia.
A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following action is the highest priority? - ANSWER Place a
tracheostomy tray at the bedside.
, - The priority action the nurse should take when using the airway, breathing, circulation
(ABC) approach to client care is place a tracheostomy tray at the client's bedside in
case of airway obstruction.
Sandbags are used to support the head and neck to prevent stress on the suture line.
Opioid medication is used to relieve pain.
The client is placed in semi Fowler's position to avoid neck extension.
A nurse is providing teaching for a client who has a new prescription for psyllium. Which
of the following information should the nurse include in the teaching? - CORRECT
ANSWER Drink 240mL of water after administration.
- The client follow each dose of psyllium with an additional 240mL of liquid.
The results should be expected in 12 to 24hr and regularly in 2 to 3days.
The client should stir the medication briskly and take it immediately after mixing to
prevent clumping.
The client should take the medication after meals to prevent appetite suppression.
A nurse is caring for a client who is having a tonic clonic seizure while in bed and has
become cyanotic. Which of the following actions should the nurse take? - CORRECT
ANSWER Prepare to suction the client's airway.
Loosen restrictive clothing on the client.
The nurse should not restrain the client or inset anything into the client's mouth. The
nurse should keep the client flat on her back or turned onto her side during a seizure
to prevent aspiration.
A nurse is assessing the incision of a client who is postoperative following a colon
resection. Which of the following findings requires intervention by the nurse? -
ANSWER Purulent drainage from incision.
- Purulent drainage indicates the presence of the infection and requires nursing
intervention.
A nurse is reviewing laboratory values for a client who has end stage kidney disease.
Which of the following laboratory values is the priority finding to report to the provider? -
ANSWER Serum potassium 6.7mEq/L
- When using the urgent vs. nonurgent approach to care, the nurse determines the
priority finding is serum potassium 6.7mEq/L because this places the client at risk for
cardiac dysrhythmias.
A nurse is providing dietary teaching for a client who has chronic kidney disease. The
nurse should instruct the client to restrict which of the following foods in his diet? -
Answer, ATI comprehensive predictor STUDY THIS ONE,
NUR325 Exam 1 ASU - ATI, Textbook Questions, NCLEX
challenge 8, ATI comprehensive, PN comprehensive
predictor practice B
A nurse is reviewing the laboratory findings of a client who had a myocardial infarction
6hr ago. Which of the following is an expected finding for this client? - CORRECT
ANSWER Troponin I 8ng/mL
- This value is above the expected reference range for Troponin I and is a specific
marker of MI.
A nurse is caring for a client who is having a febrile reaction while receiving a blood
transfusion. The nurse should administer which of the following medications? -
ANSWER Acetaminophen
- The nurse should plan to administer an antipyretic such as acetaminophen for a febrile
reaction to a blood transfusion.
Diphenhydramine for a mild allergic reaction.
Furosemide, a loop diuretic, for circulatory overload.
IV antibiotic such as cephalexin for sepsis due to receiving contaminated blood from a
transfusion.
A nurse is providing teaching for a client who has a gastric ulcer and a new prescription
for omeprazole. The nurse should instruct the client that the medication provides relief
by which of the following actions? - ANSWER Suppressing gastric acid production.
- Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric ulcers by
suppressing gastric acid production.
A nurse is administering meperidine IM in the right deltoid of a client. The nurse
aspirates and pulls back blood in the syringe. Which of the following action should the
nurse take? - ANSWER Dispose of the medication.
- The presence of blood indicate improper placement of the needle, and the solution
and needle are now contaminated. The nurse should dispose of the medication
,according to facility protocol, and obtain a new dose of medication, syringe, and needle.
A nurse is caring for a client who has COPD and is receiving nebulizer treatments of
acetylcysteine. Which of the following client statements indicates the medication is
effective? - ANSWER "I can cough up my secretions more easily now."
- Acetylcysteine thins pulmonary secretions, which increases the client's ability to cough
up secretions.
A nurse is caring for a client who has a Stage III pressure ulcer. Which of the following
should the nurse use when changing the client's dressing? - ANSWER
Hydrocolloid dressing.
- The nurse should use a hydrocolloid dressing to keep the wound bed moist.
Adhesive transparent film is used over intact skin.
Nonadherent gauze dressing is for a wound that has little to no drainage.
Wet to damp dressing is for mechanical debridement.
A nurse is reviewing the ABG values of a client who has COPD. The client's laboratory
values are pH 7.31, PaCO2 68mmHg, CO3- 26mEq/L, and PaO2 75mmHg. Which of
the following findings should the nurse expect? - ANSWER Kussmaul respirations.
- The client's ABG values indicate respiratory acidosis with manifestations of Kussmaul
respirations.
Hyperreflexia, hypertension, or tetany are expected findings in a client who has
respiratory alkalosis.
A nurse is caring for a client who has a cervical spinal cord injury sustained 1month
ago. Which of the following manifestations indicates the client is experiencing
autonomic dysreflexia? - ANSWER Heart rate 52/min
- Bradycardia is a manifestation of autonomic dysreflexia.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory findings to be below the expected reference range? - CORRECT
ANSWER Serum calcium
- A client who has pancreatitis will have decreased serum calcium due to fat necrosis.
A client presents to the clinic for a 1 week follow up visit after hospitalization for heart
failure. Based on the information in the chart, which of the following findings should the
nurse report to the provider? - ANSWER Heart rate 55/min
- This heart rate is a significant drop from baseline, and it can indicate the development
,of digoxin toxicity.
A client has a prescription for total parenteral nutrition at a rate of 3L/24hr. The
prescription calls for a 50% infusion rate for the first 24hr. The nurse should recognize
that the client will receive how may milliliters in the first 48hr? - ANSWER 4,500
- The client is receive 3,000mL per 24hr, but only half that amount for the first 24hr. So,
the client would receive 1,500mL in the first 24hr and the full 3,000mL in the second
24hr, for a total of 4,500mL for the first 48hr.
A nurse is caring for a client who has increased intracranial pressure (ICP) and received
mannitol. The nurse recognizes which of the following is an adverse effect of this
medication that should be reported to the provider? - ANSWER Headache
- Headache is an adverse effect of this medication. The nurse should notify the provider
immediately as this may indicate that the client is experiencing a rebound increase in
ICP.
A nurse is caring for a client who has biliary colic. Which of the following should the
nurse administer? - ANSWER Hydromorphone
- The nurse should administer hydromorphone to manage the client's pain caused by
biliary colic.
A nurse is assessing a client who has a stage 2 pressure ulcer. Which of the following
findings should the nurse recognize as a sign that the ulcer is healing? - CORRECT
ANSWER Moist, bright red surface in the wound bed.
- A moist, bright red wound bed indicates healing is taking place.
Erythema surrounding the wound indicates inflammation and irritation.
Brown, denatured collagen indicates necrotic tissue.
Dry, hard tissue indicates poor local arterial blood supply and lack of healing.
A nurse is assessing a client who has hypokalemia. Which of the following clinical
manifestations should the nurse expect? - ANSWER Decreased peristalsis
- Decreased peristalsis is a clinical manifestation of hypokalemia.
Facial twitching and hyperreflexia are clinical manifestations of hyperkalemia.
A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following action is the highest priority? - ANSWER Place a
tracheostomy tray at the bedside.
, - The priority action the nurse should take when using the airway, breathing, circulation
(ABC) approach to client care is place a tracheostomy tray at the client's bedside in
case of airway obstruction.
Sandbags are used to support the head and neck to prevent stress on the suture line.
Opioid medication is used to relieve pain.
The client is placed in semi Fowler's position to avoid neck extension.
A nurse is providing teaching for a client who has a new prescription for psyllium. Which
of the following information should the nurse include in the teaching? - CORRECT
ANSWER Drink 240mL of water after administration.
- The client follow each dose of psyllium with an additional 240mL of liquid.
The results should be expected in 12 to 24hr and regularly in 2 to 3days.
The client should stir the medication briskly and take it immediately after mixing to
prevent clumping.
The client should take the medication after meals to prevent appetite suppression.
A nurse is caring for a client who is having a tonic clonic seizure while in bed and has
become cyanotic. Which of the following actions should the nurse take? - CORRECT
ANSWER Prepare to suction the client's airway.
Loosen restrictive clothing on the client.
The nurse should not restrain the client or inset anything into the client's mouth. The
nurse should keep the client flat on her back or turned onto her side during a seizure
to prevent aspiration.
A nurse is assessing the incision of a client who is postoperative following a colon
resection. Which of the following findings requires intervention by the nurse? -
ANSWER Purulent drainage from incision.
- Purulent drainage indicates the presence of the infection and requires nursing
intervention.
A nurse is reviewing laboratory values for a client who has end stage kidney disease.
Which of the following laboratory values is the priority finding to report to the provider? -
ANSWER Serum potassium 6.7mEq/L
- When using the urgent vs. nonurgent approach to care, the nurse determines the
priority finding is serum potassium 6.7mEq/L because this places the client at risk for
cardiac dysrhythmias.
A nurse is providing dietary teaching for a client who has chronic kidney disease. The
nurse should instruct the client to restrict which of the following foods in his diet? -
