NR324 Midterms study,[ATI - TEST 4 PRACTICE ASSESSMENT questions and answers eith rationale[ rated A+]

ATI - TEST 4 PRACTICE ASSESSMENT A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first? C. Oxygen 2 ATI - TEST 4 PRACTICE ASSESSMEN ...

ATI - TEST 4 PRACTICE ASSESSMENT A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first? C. Oxygen 2 ATI - TEST 4 PRACTICE ASSESSMENT While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities? C. Atrial deporlarization 3 ATI - TEST 4 PRACTICE ASSESSMENT A client comes to the emergency department via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse assisting with this client client's care first? C. Initiate oxygen therapy. 4 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is preparing a client for an echocardiogram the following day. Which of the following instruction should the nurse include about this test? C. It requires lying quietly on one side. Rationale: For a Transthoracic Echocardiogram (TTE), the client lies quietly on the left side with slight head elevation. There is no reason for the client to be NPO. The test takes up to 1 hour and there is not discomfort as a transducer with conductive jelly is used on the chest. 5ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the laboratory values on a client who has HTN. Blood tests are drawn and reveal the following results. Which of the following results should the nurse identify as critical? B. Potassium 2.3 mEq/L 6 ATI - TEST 4 PRACTICE ASSESSMENT The nurse is completing a medication review of a client who has elevated cholesterol levels and takes an anticoagulant. Which of the following should the nurse report to the provider?. D. Uses garlic as a cholesterol lowering agent. Rationale: The nurse should be aware that the use of garlic to lower cholesterol may potentiate the action of anticoagulant medication and should report the finding to the provider. 7 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who enters the emergency department complaining of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? C. Perform a 12-lead ECG 8 ATI - TEST 4 PRACTICE ASSESSMENT While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2heart sounds. The nurse should document this finding as which of the following? A. A cardiac murmur Rationale: Cardiac murmurs are relatively lout, turbulent sounds the nurse can hear between usual, expected heart sounds. They create a whooshing or swishing sound. 9 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the initial laboratory values for partial thromboplastin time, and prothrombin time, and thrombin time on a client who has an acute episode of disseminated intravascular coagulation (DIC). The nurse should expect the laboratory values to be B. prolonged. Rationale: The nurse should expect the laboratory values to be prolonged because the anticoagulant pathways are impaired and consume the key clotting factors, resulting in clotting dysfunction. 10 **ATI - TEST 4 PRACTICE ASSESSMENT** A nurse is reinforcing discharge teaching for a client who has received an implantable cardioverter/defribillator (ICD). Which of the following information should the nurse include? B. The client should hold his cell phone on the side opposite the ICD. Rationale: The client should keep his cellular phone on the side opposite of the ICD, as close proximitycould interfere with the ICD's function. The client should inform airport security of the device. The client does not carry the ICD is in his pocket, this is an IMPLANTABLE device. 11 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who is postoperative following an insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.) A. Count your pulse for 1 min each morning. C. Do not wear tight clothing over the insertion area. Rationale: Avoid coming into contact with metal detectors is incorrect, there is not danger going through a metal detector, but the client should inform airport security because the pacemaker will trigger an alarm. Do not operate microwave ovens is incorrect. It is save for clients with a pacemaker to operate microwave ovens unless they are old and do not have the appropriate shielding or of they are defective. 12 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? C. The pacemaker spikes before each QRS complex. 13 ATI - TEST 4 PRACTICE ASSESSMENTA nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response? D. It prevents strokes in clients who have atrial fibrillation. Rationale: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants such as warfarin help prevent thrombosis formation. 14 ATI - TEST 4 PRACTICE ASSESSMENT A client is telling the nurse in the clinic that he gets a headache after he takes sublingual nitroglycerin (Nitrostat). Which of the following should the nurse remind the client to do? C. Lie down in a cool environment and rest. Rationale: HA is a common side effect of nitroglycerin. The nurse should suggest conservative measures to manage the HA. Generally, HAs that are a side effect of nitroglycerin are transient. They usually last about 5 min an rarely longer than 20 min. 15 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who has a new prescription for warfarin sodium (Coumadin). Which of the following should the nurse include? B. He should use an electric razor while on this medication. 16***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? A. Obtain a venous duplex ultrasound. Rationale: Venous duplex utlrasonography is a noninvasive diagnostic test used to detect distal DVT. Performing Homan's sign and dislodge the clot therefore this is inappropropriate. Warm therapy is used with DVTs not cold therapy 17 **ATI - TEST 4 PRACTICE ASSESSMENT** A client complains of SOB and chest pain the first day following multiple long bone fractures. THe nurse would consider which of the following client complications when assessing the client? B. Fat emboli Rationale: The client with a compound long bone fracture is at high risk for developing a fat embolus within 24 to 96 hr. 18 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is collecting data from an infant that has a coarctation of the aorta. Which of the following is a clinical manifestation? A. Increased blood pressure in the arms with decreased blood pressure in the legs Rationale: There is a narrowing next to the ductus areteriosus which results in an increased pressure proximal to the defect with a decreased distal to the obstruction. Therefore, an increase blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. 19 ATI - TEST 4 PRACTICE ASSESSMENTWhen checking a client's capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following? A. Arterial insufficiency Rationale: To test the capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity. 20 ATI - TEST 4 PRACTICE ASSESSMENT Whenever a nurse is caring for clients who are receiving heparin, which of the following medications should the nruse have on hand in the event of an overdose? C. Protamine 21 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who takes nitroglycerin (Nitrostat) tablet at the onset of anginal pain. AFter taking the pill, the client states that his chest pain is relieved, but then he develops a sudden pounding headache. The nurse understands that the headache is D. A common adverse reaction. 22 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is collecting data from a client who has HTN and has a prescription for propranolol (Inderal). A history of which of the following conditions should be reported to the provider? D. Heart failure Rationale:Propanolol is used with caution in clients who have heart failure to to the depressive effect on the myocardial contractility; therefore, the nurse should report this finding to the provider. 23 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who is admitted with a DVT of the left leg. Which of the following interventions should the nurse include in the client's plan of care? B. Strict bedrest Rationale: Bedrest is considered supportive therapy for DVT and should be included in the plan of care. 24 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is administering monitoring medications and realizes the nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action? A. Check the client's vital signs. Rationale: Nifedipine is an antihypertensive medication. The nurse should immediately check the client's vital signs for any significant alterations an then notify the provider. 25 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who is admitted to the hospital with CHF who has been taking digoxin (Lanoxin) 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse perform first? C. Check the client's vital signs. Rationale: Nausea is a symptom of digoxin toxicity. The nurse should take the client's vital signs to determine if the client is experiencing bradycardia. The nurse should withhold the drug and call the provider if the client has bradycardia. 26 ATI - TEST 4 PRACTICE ASSESSMENTA nurse is reinforcing teaching regarding diet to a client after a myocardial infarction. The nurse evaluates the reinforcement as effective if the client selects which of the following options? B. Baked turkey, mashed potatoes, squash and salad. Rationale: Low sodium, low fat diet is usual cardiac diet. 27 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is contributing to the care plan for a client who has developed DVT. Which of the following interventions should the nurse include? C. Elevate the affected extremity when the client is resting. Rationale: Supportive treatment for DVT includes elevation of the extremity when the client is in bed or in a chair. 28 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate? A. Bleeding Rationale: Plavix is an antithrombotic and antiplatelet aggregate used to lessen the chance of a heart attack or stroke. Bleeding precautions are implemented to limit client exposure to injury-causing events that may lead to internal or external bleeding. 29***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow? B. Patent ductus arteriosus Rationale: With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriousus and back to the pulmonary artery and lungs. 30 ATI - TEST 4 PRACTICE ASSESSMENT A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse? B. Irregular pulsations Rationale: PVCs are early ventricular depolarization that cause a pause immediately afterwards. The pause in the usual heart rhythm results in an irregular apical pulse. PVCs have a wide variety of causes, and the client typically perceives them as "palpitations." PVCs = feelings of heart skipping a beat! 31 ***ATI - TEST 4 PRACTICE ASSESSMENT*** In preparation for the discharge of a client with peripheral arterial disease PAD, the nurse should reinforce which of the following instructions? B. Adjust the thermostat so that the environment is warm.Rationale: Clients who have PAD should not wear any constrictive clothing. 32 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy? B. Apply the transdermal patch in the morning. Rationale: The client should apply the patch every morning after showering and leave it in place for a minimum of 12 hours. 33 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client on a medical surgical unit with a DVT who has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate response by the nurse? D. "Heparin will be continued until the warfarin reaches a therapeutic level." Rationale: Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, they work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which usually occurs within 1 to 5 days. When PT and INR are within therapeutic range, the heparin can be discontinued. 34 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who just had a cardiac catheterization. The post procedure nursing care plan for this client should include which of the following nursing interventions? A. Have the client rest in bed for 2 to 6 hr. Rationale: Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.35 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who enters the emergency department complaining of chest pressure and severe epigastric distress. The physician prescribes monitoring of creatine kinase (CK) isoenzymes. The nurse should paln to monitor these levels over which of the following lengths of time? D. 24 hr 36 ATI - TEST 4 PRACTICE ASSESSMENT A client who has angina pectoris is experiencing chest pain and has taken three nitroglycerin tablets sublingually. The client reports relief from the chest pain but now repots a headache. The nurse should explain to the clients that this symptom. B. is an expected side effect of the medication. 37 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril (Zestril). Which of the following instructions should the nurse plan to include? (Select all that apply.) A. "Report the development of a persistent dry cough." B. "Monitor your blood pressure on a regular basis." C. "Notify your doctor immediately if you become pregnant." 38 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching with a client who was recently diagnosed with Raynaud's phenomenon how to prevent the onset of manifestations. Which of the following statements by the client should indicate to the nurse a need for FURTHER teaching? A. "I will keep my house at a cool temperature." Rationale: Raynaud's phenomenon occurs when the client is exposed to cold temperatures or stress causing painful vasoconstriction of the blood vessels in the periphery. Keeping the house warm would help prevent manifestations of Raynaud's phenomenon. 39ATI - TEST 4 PRACTICE ASSESSMENT**** A nurse on a medical unit is caring for a client who has angina pectoris and reports chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers sublingual nitroglycerin (Nitrostat). After 5 min, the client states that his chest pain is now a 2. Which of the actions should the nurse take? A. Administer another nitroglycerin tablet. Rationale: Administration guidelines for sublingual nitroglycerin indicate that is appropriate to administer another tablet 5 min after the first if the client is still reporting pain. 40 ATI - TEST 4 PRACTICE ASSESSMENT Whenever a nurse is caring for clients who are receiving warfarin (Coumadin), which of the following medications should the nurse have on hand in the even of an overdose? D. Vitamin K 41 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with right-sided heart failure. The nurse knows that a primary manifestation is D. peripheral edema 42 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing discharge teaching for a client who will be taking warfarin (Coumadin) at home. Which of the following statements indicates that the client understands the effects of this medication?Study These Flashcards D. "I'll use my electric razor for shaving."43 ***ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for a client who is to receive digoxin (Lanoxin), verapamil (Calan), and baby aspirin (ASA) at 0900. Morning vital signs reported by the AP to the nurse include, temperature 37ºC (98.6ºF), heart rate 98/min, respiratory rate 24/min, BP 98/58 mm Hg. Which of the following actions should the nurse take? B. Recheck the client's blood pressure. Rationale: The nruse notes that the BP obtained is below the expected reference range for a client receiving an antihypertensive medication. Verapamil (Calan) is a calcium channel blocker used for treatment of angina, hypertension and arrhythmias. The nurse should verify that this blood pressure reading is accurate, then, depending on the result obtained would either administer or hold the verapamil. 44 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client following a cardiac catheterization. Which of the following is an appropriate nursing action? A. Monitor pedal pulses q15 min. 45 ATI - TEST 4 PRACTICE ASSESSMENT A client with valvular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder? C. Breath sounds Rationale:Classic manifestations of left-sided heart failure are crackles or wheezes, which the nurse can identify by monitoring the client's breath sounds. 46 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is collecting data from an older adult client who is receiving digoxin (Lanoxin): For HTN and Heart Failure. To evaluate the client for digoxin toxicity, the nurse should check forwhich of the following manifestations? A. Anorexia 47 ATI - TEST 4 PRACTICE ASSESSMENT A client tells the nurse that he is concerned because his doctor told him he has a heart murmur. The nurse should explain to the client that a murmur D. indicates turbulent blood flow through a valve Rationale: Turbulent blood tow through a valve generates a murmur, possibly due to a malfunctioning valve, increased blood flow, or some type of defect in the structures of or around the heart. 48 ATI - TEST 4 PRACTICE ASSESSMENT A client who is postoperative following surgical placement of an artificial heart valve is to be regulated on warfarin (Coumadin) prior to discharge. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy? A. Prothrombin time (PT) Rationale: The PT, reported as an INR, is used to monitor warfarin therapy. 49 ATI - TEST 4 PRACTICE ASSESSMENT A nurse in a provider's office is collecting data from a client who reports shortness of breath in the supine position and fatigue. The nurse determines that the client also has a jugular vein distention and a third heart sound (S3). Which of the following disorders should the nurse suspect? Study These Flashcards D. Mitral valve prolapse Rationale: Although many clients with mitral valve prolapse are asymptomatic, others report atypical chest pain, palpitations, exercise intolerance, dizziness, and syncope. Findings include a midsystolic click and a late systolic murmur. 50ATI - TEST 4 PRACTICE ASSESSMENT A nurse is giving a presentation about caring for clients who are receiving diuretic therapy to treat heart failure. THe nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? D. Spironolactone (Aldactone) Rationale: Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water of potassium. Thus possible adverse reaction include hyperkalemia and hyponatremia. 51 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat) sublingual tablets. The nurse verifies the client's understanding when the client states D. I'll dial 911 if one tablet does not relieve my pain and then take up to two more 5 minutes apart while waiting. Rationale: 52 ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is reinforcing teaching for an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is C. fatigue. Rationale: Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness. 53ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Frothy sputum. Rationale: Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness. 54 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reviewing the morning laboratory results of electrolytes of four cardiac clients who are receiving digoxin (Lanoxin). Which of the clients should the nurse identify as being at risk for developing digoxin toxicity? A. A client taking furosemide (Lasix) for chronic HTN.. Study These Flashcards Rationale: Loop diuretics such as furosemide, may cause hypokalemia, which greatly increases the risk of digoxin toxicity. 55 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who takes linsinopril (Zestril) should monitor for which of the following medication therapy? B. Hypotension Rationale: Linsopril, an ACE inhibitor, is used to treat hypertension and heart failure. However, in reducing blood pressure, it is possible that the client will become hypotensive. 56 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reading a client's ECG tracing. There are nine QRS complexes in a 6-second interval. What is the client's heart rate? __90___ per min57 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) C. Nausea D. Tachycardia E. Diaphoresis Rationale: Orthopnea is incorrect. It is a manifestation of heart failure., which can develop from a myocardial infarction, but it is not a common manifestation of acute MI. HA is incorrect. Chest pain and sometimes jaw and shoulder pain, not HA, are classic manifestations. Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI. Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI. 58 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who has hypertension and stable angina pectoris and is about to start taking verapamil (Calan). The nurse should instruct the client to avoid taking this medication with D. grapefruit juice. Rationale: Large amounts of grapefruit juice increase blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of drug can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness. 59 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who is about to start using sublingual nitroglycerin (Nitrostat) to treat angina pectoris. The client asks the nurse how long he has to take the medication before his condition is cured. The nurse should first A. ask the client what he knows about his diagnosis.Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows and correct any mispreconceptions before proceeding with further instructions. 60 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reading a client's ECG tracing. Which component of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? B. QT interval Rationale: The QT interval reflects the time it takes for ventricular depolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave. 61ATI - TEST 4 PRACTICE ASSESSMENT To evaluate the client following a cardiac catheterization with a left antecubital insertion site, the nurse should palpate the C. radial pulse in the left arm. Rationale: Palpating the client's pulse distal to the insertion site is essential for evaluating for thrombophlebitis and vessel occlusion. The left radial pulse should be bilateral and strong. 62 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with cirrhosis who has a prothrombin time of 30 seconds. Which of the following medications does the nurse anticipate the provider will prescribe? A. Vitamin K Rationale: A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection increases the synthesis of prothrombin by the liver, therefore; the nurse should anticipate the provider will prescribe Vitamin K. 63 ATI - TEST 4 PRACTICE ASSESSMENT A client experiencing erectile dysfunction asks the nurse about the possibility of a sildenafil (Viagra) prescription. The nurse informs the client that sildenafil is contraindicated due to the fact that the client also takesA. isosorbide (Isordil) Rationale: Sildenafil, a medication used to treat impotence in men, increases the body's ability to achieve and maintain an erection during sexual stimulation. Isosorbide is a nitrate medication used to prevent or treat angina. Clients who are on nitrates, including isosorbide and nitroglycerin preparations, should not take sildenafil due to the potential for severe hypotension. 64 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia? B. Fatigue Rationale: The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia. 65 ATI - TEST 4 PRACTICE ASSESSMENT A client has a new prescription for transdermal (Nitro-Dur) to treat angina pectoris. When talking with the patient about using this drug, the nurse should include which of the following instructions? (Select all that apply) A. Apply the patch to a hairless area and rotate sites. B. Apply a new patch each morning. C. Remove the patch for 10 to 12 hr daily. Rationale: Apply the patch to dry skin and cover the area with plastic wrap is incorrect. These instructions apply to topical nitroglycerin ointment, not to nitroglycerin patches. Apply a new patch at the onset of anginal pain is incorrect. Nitroglycerin patches prevent angina attacks. They do not treat angina attacks. 66 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? B. HepatomegalyRationale: Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure. 67 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a child who has tetralogy of Fallot and notes that the child is easily fatigued. The nurse understands that the etiology (the cause) of the fatigue is which of the following? Study These Flashcards C. Inadequate oxygenation for supporting energy metabolism Rationale: Fatigue is a direct result of the child circulating poorly oxygenated blood due to left-to-right shunting of blood. 68 ATI - TEST 4 PRACTICE ASSESSMENT A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, SOB and nausea. Which of the following actions should the nurse perform first? C. Ensure a patent airway. Rationale: Using the ABC priority setting framework, maintaining a patent airway is the first action the nurse should take. 69 ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is reinforcing discharge teaching to a client who was prescribed verapamil (Calan) for angina. Which of the following information should the nurse include? C. Sprinkle capsule contents on food. Rationale: The nurse should include in the teaching that the client may open the capsule and sprinkle on food if having difficulty swallowing. 70ATI - TEST 4 PRACTICE ASSESSMENT*** A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? C. Dull, aching, calf pain Rationale: Homan's sign is unreliable as only a small percentage of clients who have a thrombus develop it, and performing it could mobilize the clot. 71 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) B. Hypercholesterolemia C. Hypertension D. Obesity E. Smoking. 72 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is collecting data from an infant. Which of the following is a clinical manifestation of a large patent ductus arteriosus? B. Machinery-like murmur Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth causing a left-to-right shunt. A machinery-like murmur is a clinical manifestation found in infants with a large patent ductus arteriosus. 73 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is obtaining vital signs on a client who is 3 days postoperative following a coronary artery bypass surgery (CABG), and notes that the client has in irregular radial pulse of 92/min. Which of the following actions should the nurse take first? C. Count the apical heart rate for 1 minute. Rationale:When obtaining a radial pulse the nurse should count the pulse for 15 seconds and multiply the result by 4. However, this method will not result in an accurate heart rate for a client with an irregular heart rhythm. If the nurse finds that the pulse is irregular, the apical heart rate is then counted for a full minute in order to obtain the most accurate result. 74 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who is about to start taking captopril (Capoten) to treat hypertension. Which of the following instructions should the nurse include to help the client manage this medication's adverse effects? A. Do not use salt substitutes while taking this medication. 75 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is admitting a client who has acute heart failure following an MI and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification? Study These Flashcards C. 0.9% NS IV at 50 mL/hr continuous Rationale: 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarificaton. 76 ATI - TEST 4 PRACTICE ASSESSMENT Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? B. Obtain a pair of slipper socks for the client. Rationale: Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort. 77 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who has a new diagnosis of angina pectoris. The nurseshould remind the client of which of the following information about anginal pain? D. The exertion and anxiety can trigger the pain. Rationale: Exertion and anxiety can trigger the pain of angina, unless it is a variant angina, which occurs at rest. 78 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client who is taking warfarin (Coumadin) about monitoring its therapeutic effect. The nurse should explain that the provider will use international normalized ratio (INR) because D. It is standardized, so it eliminates the variations different laboratories report in prothrombin time. Rationale: The INR is a standardized test, which means that the result will be the same, not matter which laboratory performs it. The INR monitors warfarin (Coumadin) therapy, not heparin therapy. The activated partial thromboplastin time (aPTT) monitors heparin therapy. 79 ATI - TEST 4 PRACTICE ASSESSMENT A nurse in a clinic is caring for a client who has recently begun taking warfarin (Coumadin) and the nurse is reviewing potential drug and food interaction risks. The client should be instructed to avoid which of the following? A. Cabbage Rationale: Cabbage is a green leafy vegetable and rich in vitamin K. It should be avoided when taking warfarin. 80 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation in the lower extremities. Which of the following statements by the client indicates a need for further teaching? D. "I will wear stockings with elastic tops." Rationale:Elastic tops on stockings further impair circulation and should b avoided by clients with circulation problems. 81 ATI - TEST 4 PRACTICE ASSESSMENT A client who is taking medications to treat hypertension has a potassium level of 6.8 mEq/L. Besides notifying the provider, which of the following actions should the nurse take? B. Obtain a 12-lead ECG. Rationale: This client's K+ level is elevated. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes. 82 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat). The nurse should remind to take the medication C. at first indication of chest pain. Rationale: The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and, not wait until the chest pain is severe. 83 ATI - TEST 4 PRACTICE ASSESSMENT When collecting data from a client who has atrial fibrillation, the nurse would expect his pulse to beC. Irregular. Rationale: With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse. 84 ATI - TEST 4 PRACTICE ASSESSMENT The nurse is caring for a client receiving nifedipine (Procardia). When the nurse checks the client's BP prior to administering the medication, it is 98/58. Which of the following actions should the nurse take first? A. Recheck the client's blood pressure. Rationale: A BP of 98/58 is too low to permit administration of nifedipine. Therefore, the nurse must recheck the BP before taking any further action. 85 ATI - TEST 4 PRACTICE ASSESSMENT The nurse collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect? D. SOB while lying down Rationale: Orthopnea, or SOB when the client lies down, is a characteristic manifestation of left-sided heart failure. Increased lung pressures from interstitial and alveolar edema causes it. 86 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a child with Kawasaki disease. Which of the following is the primary system involved with this diagnosis? A. Cardiovascular Rationale:Cardiovascular changes occur in children diagnosed with Kawasaki disease due to inflammation of the arterioles, venules, and capillaries; therefore, this is the primary system involved with this diagnosis. 87 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is talking with a client who is about to start taking nitroglycerin oral, sustained-released capsules (Nitro-Time). Which of the following instructions should the nurse include? D. Swallow the capsules whole. Rationale: The client should swallow the capsules whole and not chew or crush them or place them under the tongue. 88 ATI - TEST 4 PRACTICE ASSESSMENT A nurse on a medical unit is caring for a client who has infective endocarditis. The nurse should observe this client for manifestations of a common complication of this disorder by monitoring for B. dyspnea Rationale: Emboli are the major problem; those arising in the right heart chambers will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities. Fever is a manifestation of infective endocarditis, not of its complications. 89 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who has a blood pressure of 156/98. Which of the following findings would the client manifest with Stage 1 hypertension? A. Vertigo Rationale: The client may manifest blurred vision with malignant hypertensive. 90ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who has thrombophlebitis and has been placed on IV heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses by the nurse is appropriate? C. "Heparin prevents new clots from forming rather than dissolving established clots." Rationale: Heparin is given to prevent the formation of new clots by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin. It does not dissolve established clots. 91 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is preparing to administer digoxin (Lanoxin) to a client who has heart failure. Which of the following actions is appropriate? D. Evaluating the client for nausea, vomiting, and anorexia. Rationale: Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity. 92 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client with infective endocarditis. Which of the following is a priority manifestation the nurse should monitor for? B. Dyspnea Rationale: When using the ABC approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization. Fever is a manifestation associated with infective endocarditis, but another manifestation is a greater risk to the client, and therefore a higher priority for the nurse to monitor for.93 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is preparing to administer heparin intravenously to a client. Which of the following is an appropriate nursing action? A. Obtain an infusion pump to regulate the continuous flow of the medication. Rationale: Because of the risk for bleeding, an infusion pump must be used to prevent overdosage and its rate checked q30 to 60 min. The activated partial thromboplastin time (aPTT), not the PT is measured to determine the effectiveness of a heparin drip. 94 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing teaching to a group of premenopausal women about activities to reduce the risk of developing coronary artery disease. Which of the following statements by a client requires clarification? D. "Increasing the intake of foods containing trans-fatty acids in my diet can lower my risk." Rationale: Increasing dietary intake of trans fatty acids increases the risk of developing coronary artery disease.95 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is reinforcing discharge instructions for a client who developed DVT postoperatively and receives anticoagulant therapy. Which of the following instructions should the nurse include? C. Flexing her knees and feet frequently. Rationale: Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting. The client should not take any NSAIDs because they can potentiate the action of the anticoagulant and put her at risk for bleeding. 96 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who is prescribed aspirin (Ecotrin) 325 mg and has a history of a previous MI. The nurse instructs the client that the aspirin is prescribed once daily due to its action as an C. antiplatelet aggregate 97 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is caring for a client who receives digoxin (Lanoxin). Before administering this medicaiton, which of the following actions should the nurse take? C. Measure the client's apical pulse. 98 ATI - TEST 4 PRACTICE ASSESSMENT A nurse is assisting with the care of an older adult client who has had a cardiac catheterization. Which nursing interventions should the nurse contribute to the client's plan of care for the next 8 hr? (Select all that apply)A. Check peripheral pulse in the affected extremity. B. Place the client in high Fowler's position. C. Measure the client's vital signs q4h. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr. Study These Flashcards