ATI Adult Medical-Surgical Nursing Nclex Questions

ATI Adult Medical-Surgical Nursing Nclex Questions Stephanie Smith Chapter 26 – Respiratory Failure 1. A nurse in an emergency department is assessing a client who was in a MVC. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6℃ (101.4℉), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access. Rationale: C- According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore optimal breathing. 2. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. “This medication is given to treat infection.” B. “This medication is given to facilitate ventilation.” C. “This medication is given to decrease inflammation.” D. “This medication is given to reduce anxiety.” Rationale: B- Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption. 3. A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following a coronary artery bypass graft surgery. C. A client who has a hemoglobin of 15.1 mg/Dl D. A client who has dysphagia E. A client who experienced a drug overdose Rationale: A, B, D, E- A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. A client who experienced a drug overdose is at risk for developing ARDS due to damage to the central nervous system. 4. A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for the client? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support. Rationale: B, D, E- Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered given to treat severe hypoxemia. Administering of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client’s airway. Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway. 5. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Dexamethasone Rationale: A, C- Fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. Midazolam is a sedative medication used to treat clients with ARDS when a neuromuscular blocking agent such as vecuronium is administered. Chapter 27 – Cardiovascular Diagnostic and Therapeutic Procedures 1. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. “Air should be instilled into the monitoring system prior to the procedure.” B. “The client should be positioned on the left side during the procedure.” C. “The transducer should be level with the second intercostal space after the line is placed.” D. “A chest x-ray is needed to verify placement after the procedure?” Rationale: D- The nurse should ensure that a chest x-ray is obtained to confirm proper placement of the lines following placement. 2. A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following finding should the nurse expect? A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distension D. Dry mucous membranes E. Hepatomegaly Rationale: B, C, E- The nurse should expect the client to have bilateral crackles in the lungs for an increased CVP and PAWP. The nurse should expect the client to have jugular vein distention for an increased CVP and PAWP. The nurse should expect the client to have hepatomegaly for an increased CVP and PAWP. 3. A nurse is teaching a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? (Select all that apply.) A. “You should have nothing to eat or drink for 4 hours prior to the procedure.” B. “You will be given general anesthesia during the procedure.” C. “You should not have this procedure done if you are allergic to eggs.” D. “You will need to keep your affected leg straight following the procedure.” Rationale: D- The nurse should instruct the client of the need to remain on bed rest in the supine position with the affected leg straight for a prescribed amount of time. This positioning decreases the client’s risk for bleeding and hematoma formation at the catheter insertion site. 4. A nurse at a provider’s office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/Dl B. HDL 90 mg/dL C. LDL 140 mg/Dl D. Triglycerides 125 mg/Dl E. Troponin I 0.02 ng/mL Rationale: A, C- A client who has a total cholesterol level greater than 200 mg/Dl is at increased risk for heart disease. A client who has an LDL greater than 130 mg/Dl is at increased risk for heart disease. 5. A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Use a 10 mL syringe to flush the PICC line. B. Apply gentle force if resistance is met during injection. C. Cleanse ports with alcohol for 15 seconds prior to use. D. Maintain a transport dressing over the insertion sit. E. Flush with 10 mL heparin before and after medication administration. Rationale: A, C, D- The nurse should use a 10 mL syringe to flush the PICC line to avoid excess pressure that could cause catheter fracture/rupture. The nurse should cleanse insertion ports with alcohol for 15 seconds and allow it to air dry prior to use. This action decreases the risk for bacterial contamination. The nurse should maintain a transparent dressing over the insertion site to decrease the risk for infection and allow for visualization. The nurse should plan to change the dressing at least every 7 days and when wet, loose, or soiled. Chapter 28 – Electrocardiography and Dysrhythmia Monitoring 1. A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who had COPD E. A client who underwent stent placement in a coronary artery Rationale: A, D, E- A client who has an acid-base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. A client who has lung disease, such as COPD, is at risk for a dysrhythmia. A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia. 2. A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? (Review the data below for additional client information) MAR: Ferrous Sulfate 200 mg PO 0800 and 2000 Diazepam 2 mg PO 0800 and 2000 Isosorbide 2.5 mg PO 4 times a day AC and HS VITAL SIGNS: 0800 – T 99.5F Blood pressure 142/86 mm Hg Heart rate 88/min and irregular Respirations 20/min HISTORY & PHYSICAL: Bariatric surgery 10 years ago Dyspnea with exertion for 3 years Atrial fibrillation began 3 years ago Client reports taking the following medications for the past 6 weeks: Iron supplement, multivitamin, antilipemic, and nitroglycerin A. Respiratory history B. Vital signs C. Medication history D. Medications to be administered Rationale: C- A client who is to undergo cardioversion needs to be on anticoagulant therapy for 4-6 weeks prior to the procedure. 3. A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow-up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes Rationale: A, B, E- The client’s ECG rhythm is documented following the procedure. Energy settings used during the procedure are documented. The condition of the client’s skin where the electrodes were placed is documented. 4. A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client’s heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine Rationale: B- A client who has bradycardia is a candidate for a pacemaker to increase the heart rate. 5. A student nurse is observing a cardioversion procedure and hears the team leader call out, “Stand clear.” The student should recognize the purpose of this action is to alert personnel that A. The cardioverter is being charged to the appropriate setting. B. They should initiate CPR due to pulseless electrical activity. C. They cannot be in contact with equipment connected to the client. D. A time-out is being called to verify correct protocols. Rationale: C- A safety concern for personnel performing cardioversion is to “stand clear” of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock. Chapter 29 – Pacemakers 1. A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client’s heart rate is 34/min and blood pressure is 83/48 mm Hg. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a permanent pacemaker. C. Obtain a signed informed consent form for a pacemaker. D. Apply transcutaneous pacemaker pads. Rationale: D- The greatest risk to this client is injury or death from inadequate tissue perfusion; therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and begin external pacing of the heart until a permanent pacemaker can be placed. 2. A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mm Hg Rationale: A, C- A cool, clammy foot can be an indication of a femoral hematoma secondary to insertion of the lead wires and should be reported. Persistent hiccups can indicate lead wire perforation and stimulation of the diaphragm and should be reported. 3. A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. “I will notify the airport screeners about my pacemaker.” B. “I will expect to have occasional hiccups.” C. “I will have to disconnect my garage door opener.” D. “I will take my pulse every 2 days.” Rationale: A- The client should notify airport screening personnel about a pacemaker. 4. A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? A. “This means the pacemaker fires in an asynchronous pattern.” B. “This means the pacemaker fires only when the heart rate is below a certain rate.” C. “The pacemaker can automatically adjust to a client’s increased activity level.” D. “The pacemaker activity is triggered by heart muscle activity.” Rationale: A- Fixed rate mode is asynchronous, meaning the pacemaker fires without regard for electrical activity in the heart. 5. A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? (Select all that apply.) A. Wear gloves when handling pacemaker leads. B. Ensure electronic equipment has three-pronged grounding plugs. C. Minimize the client’s shoulder movements. D. Hold the lead wires taut when turning the client. E. Keep extra pacemaker batteries at least 300 feet away from the client. Rationale: A, C- The nurse should wear gloves when handling pacemaker leads. The client should wear a sling to minimize shoulder movement and promote secure anchoring of the lead wires. Ch. 30 – Invasive Cardiovascular Procedures 1. A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following actions should the nurse take? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia. Rationale: B- Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness. 2. A nurse is caring for a client following peripheral bypass graft surgery of the lower left extremity. Which of the following findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb Rationale: B, C- Capillary refill greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider. Mottled appearance of the affected extremity is an unexpected finding and should be reported to the provider. 3. A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? (Select all that apply.) A. “The client’s demand for oxygen is lowered.” B. “Motion of the heart ceases.” C. “Rewarming of the client takes place.” D. “The client’s metabolic rate is increased.” E. “Blood flow to the heart is stopped.” Rationale: A, B, C- The use of cardiopulmonary bypass reduces the client’s demand for oxygen, which reduces the risk of inadequate oxygenation of vital organs. Motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery. The core body temperature is lowered for the procedure, and rewarming then occurs through heart exchanges on the cardiopulmonary bypass machine. 4. A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client’s lower back. Which of the following findings should the nurse expect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure Rationale: C- Bleeding is occurring from the incision site and then draining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider. 5. A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg Rationale: D- A client who has peripheral artery disease might report that numbness or burning pain in the extremity ceases with rest (intermittent claudication). Chapter 31 – Angina and Myocardial Infarction 1. A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 minutes. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 minutes. Rationale: A- Angina can be relieved by rest and nitroglycerin. 2. A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin Rationale: C- The Troponin T level will still be evident 10-14 days following an MI. 3. A nurse is caring for a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? A. “Aspirin reduces the formation of blood clots that could cause a heart attack.” B. “Aspirin relieves the pain due to myocardial ischemia.” C. “Aspirin dissolves clots that are forming in your coronary arteries.” D. “Aspirin relieves headaches that are caused by other medications.” Rationale: A- Aspiring decreases platelet aggregation that can cause myocardial infarction. 4. A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. “I should place the tablet