ATI RN Level 2 Practice A V2 (NEW 2026/2027) Concept-Based Assessment | Full Questions, Verified Answers & Rationales | Guaranteed A

ATI RN Level 2 Practice A V2 (NEW 2026/2027) Concept-Based Assessment | Full Questions, Verified Answers & Rationales | Guaranteed A Q. A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry ANSWER Observe the client perform incentive spirometry When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions. Q. A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements -The client's weight is 1.4 kg (3.1 lb) less than baseline ANSWER The client reports sleeping longer during the night The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication. Q. A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr ANSWER Monitor the site daily for drainage The nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider. Q. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? -Intake of fluid is less than output of urine over the past 2 days -1kg (2.2 lb) weight gain over the past 2 days -Blood glucose 206 mg/dL -Prealbumin 13 mg/dL ANSWER 1 kg (2.2 lb) weight gain over the past 2 days Total parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition. Q. A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess? ANSWER Right upper quadrant The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client's abdomen to the client's right shoulder. Q. The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds" -"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea" ANSWER "Consume a clear liquid diet until symptoms resolve" The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility. Q. A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth ANSWER I will wash all uninfected skin areas with a fresh washcloth The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection. Q. A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal ANSWER Keep your mouth open when sneezing The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum. Q. A nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4-year-old son is expected to react to the death of his partner. Which of the following information should the nurse include in the teaching? -A preschooler has no concept of death -A preschooler is often interested in what happens to the body after death -A preschooler often believes that death is reversible -A preschooler understands that death happens to everyone ANSWER A preschooler often believes that death is reversible The nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die. Q. A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools ANSWER Increased urination The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. Q. A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm ANSWER Numbness to the fingers on the right arm The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses. Q. A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by MRSA. Which of the following client statements indicates an understanding of the teaching? -I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach -I will wash my clothes in cold water and detergent -I will throw away my razor after using it three times -I will apply imiquimod cream to the lesions before going to bed each night ANSWER I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection. Q. A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? -Peak expiratory flow meter testing -Spirometry monitoring -Pulmonary function testing -Chest x-ray ANSWER Peak expiratory flow meter testing The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help. Q. A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of this medication? -Increased salivation -Bradycardia -Tinnitus -Distended bladder ANSWER Distended bladder The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client's intake and output and assess for bladder distention. Q. A nurse is planning discharge for a postpartum client. The client tells the nurse she is having subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? -Irregular bleeding -Fatigue -Shoulder pain -Recurrent urinary tract infections (UTIs) ANSWER Irregular bleeding The nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal. Q. A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis ANSWER Gonorrhea Gonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention. Q. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? ANSWER -fever -abdominal ascites -anxious -nasogastric suctioning A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. Q. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? -Brown discoloration of the lower extremities -Superficial ulcer on the medial aspect of the ankle -Dependent rubor -Telangiectasias ANSWER Dependent rubor The nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position. A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? -Jugular vein distention -Fatigue -Angina -Hacking cough Jugular vein distention The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system. A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus Globus The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat. A nurse is preparing to mix NPH insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow. 1. Inject air into the vial equal to the amount of NPH insulin prescribed 2. Inject air into the vial equal to the amount of insulin aspart prescribed 3. Withdraw the prescribed volume of insulin aspart into the syringe 4. Withdraw the prescribed volume of NPH insulin into the syringe A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? Select all that apply Fever, Dyspepsia, Eructation A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? -Apply warm dary packs initially then apply cool moist packs to the lower extremity -Elevate the extremity 7.6 to 15.2 cm above heart level -Gently massage the affected extremity for 10-15 min every shift -Apply a topical corticosteroid to any open areas on the affected extremity twice per day Elevate the extremity 7.6 to 15.2 cm above heart level The nurse should elevate the client's affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema. A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication I will return to have my cholesterol levels checked in 2 weeks A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? -Flushed, dry skin -Seizures -Hyperreflexia -Positive Trousseau's sign Flushed, dry skin The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2. A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? -restrict oral intake to clear fluids -place a heating pad on the client's abdomen -place the client in semi-Fowler's position -Administer an enema Place the client in semi-Fowler's position The nurse should place the client in semi-Fowler's position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum. A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? -BMI 26 or above -Excessive sun exposure -Frequent weight-bearing exercise -Hip fracture 6 months ago Hip fracture 6 months ago The nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis. A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply Lidocaine 5% patches, Celecoxib, Cyclobenzaprine, Glucosamine A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? -Flank pain with radiation toward the scrotum -150 mL emesis -Oliguria with bladder distention -Blood pressure 160/90 mmHg Oliguria with bladder distention The greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately. A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? -Total bilirubin 0.8 mg/dL -WBC count 4,000/mm^3 -Platelets 190,000/mm^3 -Creatinine 1 mg/dL WBC count 4,000/mm^3 Agranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication. A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media ? -Enlarged postauricular lymph nodes -Increased flatulence with constipation -Indicates a desire to such more frequently -Slow bounding heart rate Enlarged postauricular lymph nodes The nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F). A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL HDL 50 mg/dL This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client. A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? -Orthostatic hypotension -Hoarse voice -Neck vein distention -Muscle twitching Orthostatic hypotension The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy. A nurse is admitting a client who has peptic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? Select all that apply Dark tarry stools, bright red emesis, increased heart rate A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? -Weight gain -Enlarged liver -Distended abdomen -Cool extremities Cool extremities The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion. A nurse is providing teaching about home care with a parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? I should wash my child's bed linens and clothing in hot water and detergent A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? Albumin level A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? Elevated aspartate aminotransferase levels A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching? I will wash my hands whenever I come home from the grocery store A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? Sputum culture shows gram positive bacteria A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? I should limit wearing the same shoes 2 days in a row A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include? Perform exercise even on days when joints are painful A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? Use albuterol prior to planned exercise A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? Urinary burning A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? Tall T-waves A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? Feeling anger toward family members A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include? Comb the child's hair daily with an extra fine-tooth comb A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? Focuses on the source of anxiety A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider? onset of abdominal pain A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis? Diabetes mellitus A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? Megestrol A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? A black bean burger on a whole grain bun A nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items? Caffeinated coffee A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect? Ribbon-like stools A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the infant A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? Hypotension A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? Cold intolerance A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? Start IV fluid replacement A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? Do not bathe your newborn immediately after she eats A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate? One hand on gait belt walking behind the patient on affected side (right side) A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? File your toenails straight across to prevent ingrown toenails A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include? Bathe, diaper, and dress the child before bringing the newborn to the client A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? Inaudible lung sounds A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? Report of urinating small amounts twice daily A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? Place the affected areas of frostbite in a warm water bath A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile? Vancomycin A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? Place a surgical mask on the client A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan? Elevate the client's arm above the heart A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? Capillary refill greater than 2 seconds A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? Potassium 3 mEq/L A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? Acrophobia A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? Escitalopram A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? nasal flaring A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? Apply humidified oxygen with simple mask A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe? Protamine sulfate A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? Stay with the client until manifestations subside A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? Heredity A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment? Hypertension A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? I should avoid using the vacuum cleaner for several weeks A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take? Contact a specialized team to place the client on cardiopulmonary bypass A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? Oliguria A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? Confusion A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching? perform exercises to strengthen the abdominal core A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? drink fluids between, rather than with, meals A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider? Black, tarry stools A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? Hydrochlorothiazide A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? I avoid thinking about problems that worry me until I have time to focus on a solution A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? Long-term use of NSAIDs A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? Ondansetron A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? The client lost his house in a house fire 1 month ago A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need? The client reports coughing and a change of voice whenever he eats A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include? Give a second injection if the first fails to reverse your child's symptoms A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? Creatinine 2.5 mg/dL A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? Bradycardia A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? What are some of the best times with your partner that you remember? A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching? This medication could cause you to have thoughts of self-harm A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? place the client in high-Fowler's position A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? Avoid giving aspirin to your child A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? Congenital heart disease A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching? I will breathe out slowly through pursed lips if I feel short of breath A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider? Pain report A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? I'll wash my feet everyday with soap and lukewarm water A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first? Ensure a patent airway using a chin-lift maneuver A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? Aspartate aminotransferase (AST) 45 units/L A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? One small orange A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? Limit the amount of spinach in your diet A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? Swelling A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances? Respiratory alkalosis A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply Abdominal distention, vomiting, hyperactive bowel sounds A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? A: "Let's talk about a few ways you have dealt with stress in the past." Rationale: This statement by the nurse combines two therapeutic responses, active listening and focusing. Used together, these techniques facilitate communication by letting the parent know one's feelings are heard and taken seriously, which conveys acceptance and respect. Therefore, the parent feels the nurse validates the concerns and becomes comfortable asking the nurse sensitive questions about the child. A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching? A: "Maintain bone health by eating fruits, vegetables, and protein." Rationale: The nurse should instruct the client that the best way to maintain bone health and bone remodeling is by eating fruits, vegetables, and protein. A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make? B: "This medication causes adverse effects if the dosage is too high or too low." Rationale: The nurse should instruct the client that levothyroxine, in the right dosage, does not typically cause adverse effects. If the dosage is too low, the manifestations of hypothyroidism will recur. If the dosage is too high, the manifestations of hyperthyroidism will occur. A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? D: Brisk skin turgor Rationale: The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective. A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? B: Encourage the client to use wide-grip utensils when eating with the right hand. Rationale: The nurse should encourage the client who has hemiparesis to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating. A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia? D: Garlic Rationale: The nurse should include that garlic can help improve cholesterol levels, which then helps to reduce the buildup of plaque in the arteries. For some clients, it can also help lower blood pressure A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take? D: Set the temperature of the client's room to 22.2° C (72°). Rationale: The nurse should set the temperature of the client's room at 21° C to 27° C (70° F to 80° F). This promotes a reduction in the client's fever without causing shivering. By combining nonpharmacological interventions with antipyretics, the nurse can reduce the client's fever. A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care? C: Check for paresthesia of the affected leg. Rationale: The nurse should include in the interventions to check for paresthesia, such as a tingling sensation of the leg and foot, which can indicate manifestations of neurovascular compromise or compartment syndrome. A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? B: Presence of strabismus Rationale: The nurse should recognize that the presence of strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report this finding to the provider. A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? C: Increase fiber intake to at least 30 g per day. Rationale: The nurse should instruct the client to increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis. A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? B: Discoloration and edema of the right ankle Rationale: The nurse should identify that manifestations of peripheral venous disease include discoloration and edema of the ankle, resulting from venous hypertension. A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? D: "Perform Kegel exercises several times throughout the day." Rationale: The nurse should instruct the client on the performance of Kegel exercises, or tightening and then relaxing the urinary sphincter, to assist the client in regaining urinary control and eliminate dribbling or the leakage of urine. The nurse should encourage the client to perform these exercises several times each day. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.) A: Nocturia C: Dyspnea D: Hacking cough Rationale: Left-sided heart failure causes oliguria during the day and nocturia during sleeping hours, pulmonary manifestations, such as dyspnea, orthopnea, crackles, and wheezes, and a hacking cough that worsens at night and eventually produces frothy sputum. A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? C: The catheter tubing has multiple red clots. Rationale: The nurse should identify that the presence of multiple red clots in the catheter tubing or drainage that is ketchup-like are manifestations of postoperative bleeding. The nurse should notify the provider and provide hand irrigation of the bladder per provider prescription. A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? D: Plan to finish eating at least 3 hr before bedtime. Rationale: The nurse should encourage the client not to eat anything at least 3 hr before bedtime to prevent reflux. A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination? B: "Void as soon as you feel the urge." Rationale: The nurse should instruct a client who has BPH on measures to prevent distension of the bladder and urinary retention. Encouraging the client to void as soon as the urge develops decreases the risk of bladder distension. A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect? C: Decreased level of consciousness Rationale: The nurse should expect a client who has hyponatremia to have cerebral edema and increased intracranial pressure as fluid moves into the cells in the brain. This can manifest as confusion, changes in level of consciousness, and seizures. A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching? C: "I will base my peak flow meter score on the best of three attempts." Rationale: The client's peak flow rate should be based on the best of three trials of the peak flow meter. The client should record this finding and share it with the provider on the next visit. A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? B: Fruity breath odor Rationale: The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion. A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect? A: Hypoglycemia Rationale: The nurse should expect an infant who has hypothermia to have hypoglycemia. Other manifestations of hypothermia include apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia. A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include? D: Drink 120 mL (4 oz) of fruit juice. Rationale: The nurse should instruct the client to drink 120 mL (4 oz) of fruit juice, which will provide 10 to 15 g of carbohydrates to treat the hypoglycemia. A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take? B: Remain with the client until manifestations subside. Rationale: The nurse should remain with the client in a quiet place throughout the panic attack to ensure the client's safety and assist with anxiety reduction techniques. A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? A: Apply ice packs to the client's axillae, neck, groin, and chest. Rationale: The nurse should recognize that treatment for heat stroke involves cooling the client's core body temperature quickly. The nurse should apply ice to the client's axillae, neck, groin, and chest while also spraying the client's body with tepid water. A nurse in a provider's office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse's intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) D: Coagulation time Rationale: The nurse should report the client's coagulation time, or INR, to the provider immediately because it is above the expected reference range, which predisposes the client to intraoperative and/or postoperative hemorrhage. The nurse should expect the provider to postpone the joint arthroplasty until the client's clotting time is within the expected reference range. A nurse is planning care for a client who has pneumonia. WHich of the following interventions should the nurse include in the plan? C: Teach the client how to cough up secretions. Rationale: The nurse should instruct the client how to cough and breathe deeply to expel productive secretions and clear the airway for optimal breathing. A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? B: Hemoglobin 7.6 mg/dL Rationale: The nurse should identify that with Cushing's disease, also known as hypercortisolism, adrenocorticotropic hormone levels are low due to hypersecretion of the adrenal cortex. This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells. A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record? B; Agoraphobia Rationale: The nurse should document that the client is experiencing agoraphobia in the client's medical record. Agoraphobia is the fear of being outside and can be debilitating and limit a client's ability to function. A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? C: Initiate droplet precautions for the child. Rationale: The nurse should initiate droplet precautions for a child who has pertussis, which is spread by large droplets in the air; therefore, the nurse should wear a surgical mask within 1 m (3.3 feet) of the child. A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include? B: "Do not drink alcohol while taking this medication." Rationale: The nurse should instruct the client that rifampin could cause liver damage. Alcohol intensifies this risk. Rifampin is contraindicated for clients who have liver disease or consume alcohol in excess. A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances? B: Metabolic alkalosis Rationale: The nurse should identify that with Cushing's disease, also known as hypercortisolism, adrenocorticotropic hormone levels are low due to hypersecretion of the adrenal cortex. This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells. A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan? D: Monitor for hypertension. Rationale: The nurse should monitor the client's blood pressure while receiving epoetin to identify and treat hypertension. Hypertension and cardiovascular events, such as myocardial infarction and stroke, are adverse effects of epoetin. A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? B: Touches the colostomy stoma when the bag is changed Rationale: The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief. A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? C: Respiratory acidosis Rationale: With this acid-base imbalance, the client's pH is below the expected reference range, the PaCO2 is above the expected reference range, and the HCO3- is within or possibly above the expected reference range. Common causes of respiratory acidosis are respiratory depression due to anesthesia or opioid administration, airway obstruction, and inadequate chest expansion. A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching? C: Morbid obesity is measured as a BMI over 40. Rationale: The nurse should instruct the client that the expected reference range for a healthy weight is a BMI of 25 or less. A client who has a BMI of 40 or greater is considered morbidly obese. A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? C: The stoma is purple in color. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply. A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? C: Positive leukocyte esterase Rationale: The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection. A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? C: "Wash your hands when you return home from running errands." Rationale: The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia. A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take? A: Encourage the client to repeat what the nurse has said. Rationale: The nurse should have the client repeat back what is discussed. The nurse should not rely on the client's nonverbal communications, such as a nod of the head, to ensure the client understands the information. A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? A: "The adhesive bandages on my incision will fall off as the incision heals." Rationale: The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals. A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect? C: Facial eruption Rationale: The nurse should identify that facial eruption, predominantly located on the cheeks, is a manifestation of erythema infectiosum. The child has a "slapped face" appearance. The eruption generally disappears after 4 days, but can reappear if the skin is traumatized or irritated by sun, heat, cold, or friction. A nurse is planning care for a client who has renal calculi. Which of the following interventions should the nurse include to promote elimination of the calculi? C: Encourage intake of at least 3 L of fluid each day. Rationale: The nurse should encourage the client to consume at least 3 L of fluid each day. Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence. A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? D: Follows directions Rationale: The nurse should expect a client who is experiencing a mild level of anxiety to be able to follow directions and focus on the nurse's instructions. Other manifestations the nurse should expect include restlessness, heightened perception, and ability to problem solve. A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority? B: Protect the client from harm. Rationale: The greatest risk to this client is injury from uncontrollable thoughts and activity; therefore, the priority intervention is to protect the client from harming himself or others by moving to a quiet environment with decreased stimulation and staying with the client. A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? C: Elevate the wrist above heart level. Rationale: The nurse should instruct the client to elevate the wrist above heart level to reduce swelling and minimize pain. A nurse is caring for a middle adult female client who has atrial fibrillation and is taking warfarin. The nurse should recognize which of the following as an adverse effect of the medication and notify the provider? B: Increased menstrual flow Rationale: The nurse should identify that warfarin is an anticoagulant used to prevent the development of thrombosis. It suppresses coagulation, which increases the risk for bleeding. The nurse should identify indications of bleeding and hemorrhage, such as increased menstrual flow, bruising, bleeding gums, and black, tarry stools, as adverse effects of warfarin therapy and notify the provider. A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care? C: Make sure the client's legs are elevated while in bed. Rationale: The nurse should ensure the client elevates her legs in bed and wears antiembolic stockings to help prevent venous insufficiency. A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as a priority? A: Determine the client's knowledge regarding gestational diabetes. Rationale: The first action the nurse should take when using the nursing process is to assess the client. It is important for the nurse to determine the client's knowledge level regarding the disease process. This provides the nurse with information regarding where to start with the client teaching process. A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect? A: Progressive loss of peripheral vision Rationale: The nurse should expect a client who has POAG to report a progressive loss of peripheral vision. The nurse should perform visual field testing to determine the severity of the peripheral vision loss. The nurse should also expect diagnostic assessment to indicate increased intraocular pressure. A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? B: Vomiting Rationale: The nurse should identify that heat exhaustion is usually the result of excess sweating, leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness, fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F). A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death? D: Adolescents often alienate themselves from their peers when grieving. Rationale: The nurse should identify that adolescents dealing with death often have difficulty communicating their feelings and alienate themselves from their peers and families. A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium? B: Collard greens Rationale: The nurse should determine that collard greens are the best food source to recommend because 1 cup contains 268 mg of calcium per serving. A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client? D: Protamine Rationale: When there are manifestations of a heparin overdose, the nurse should anticipate that the provider might prescribe protamine to inactivate the heparin. In addition, the nurse should decrease or stop the heparin therapy for a period of time and recheck the aPTT level prior to restarting the heparin. The effects of protamine will last up to 2 hr. A nurse is assessing a client who is postoperative following the placement of an ileostomy due to complication of ulcerative colitis. In which of the following areas should the nurse expect the ileostomy to be located? (You will hind hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) C: Right lower abdomen inferior to umbilicus. Rationale: An ileostomy is a surgical procedure that creates a stoma from a section of the client's ileum. The stoma is located on the right side, lateral to, and slightly below the umbilicus. A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? D: "I should add 1 teaspoon of rice cereal to my infant's formula." Rationale: The parent should add 1 teaspoon to 1 tablespoon of rice cereal in order to thicken the formula. This will decrease the incidence of gastric reflux. A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? D: Lipase 185 units/L Rationale: The nurse should recognize that an elevated lipase is an indication of pancreatitis, which can indicate the client is experiencing an adverse effect to exenatide. Physical manifestations of pancreatitis include ongoing, severe abdominal pain and vomiting. A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain. The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following medications should the nurse anticipate the provider will prescribe for the client? A: Naloxone Rationale: The nurse should expect the provider to prescribe naloxone for the client. Naloxone is an opiate antagonist that reverses the effects of opioids, such as morphine. Naloxone reverses respiratory depression and sedation. A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis? B: Client is taking atorvastatin. Rationale: The nurse should identify that increased serum cholesterol and taking cholesterol-lowering medications, such as atorvastatin, increases the client's risk of developing cholecystitis. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3 24 mEq/L. Which of the following findings should the nurse expect