ATI Exam 3 NCLEX Examination Questions

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jessicawalden2 Preview ATI practice NCLEX questions 56 terms emilee_h21Preview NCLEX-RN Exam Learning System 3....22 terms kkblayPreview PN Adu 90 terms kgo A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complication should the nurse monitor for postoperatively? SATAA.

• Increased ICP
• Hemorrhagic shock
• Hydrocephalus
• Hypoglycemia
• Seizures
• Increased ICP
• Hydrocephalus
• Seizures

rationale: hemorrhagic shock occurs secondary to SIADH and hypoglycemia is

not a concern for brain surgery A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following prescriptions should the nurse clarify with the provider?

• dexamethasone
• morphine sulfate
• Ondansetron
• phenytoin
• morphine sulfate

rationale: opioid meds should be questioned due to their ability to decrease level of consciousness especially after brain surgery A nurse is completing an assessment of a client who has increased ICP. Which of the following are expected findings? SATA

• Disoriented to time and place
• Restlessness and irritability
• Unequal pupils
• ICP of 15 mm/Hg
• Headache

A.Disoriented to time and place

• Restlessness and irritability
• Unequal pupils
• Headache

rationale: ICP of 15 is w/in normal range

A nurse is reviewing a prescription for dexamethasone (Decadron) with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? SATA

• "It's given to reduce swelling of the brain"
• "You will need to monitor for low blood sugar"
• "You may notice weight gain"
• "Tumor growth will be delayed"
• "It can cause you to retain fluids"
• "It's given to reduce swelling of the brain"
• "You may notice weight gain"
• "It can cause you to retain fluids"

rationale: it reduces cerebral edema, hyperglycemia,fluid retention and weight

gain are adverse effects, it does not affect tumor growth A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse?

• "It can spread to breasts and kidneys"
• "It can develop in your GI tract"
• "It is limited to brain tissue"
• "It probably started in another area of your body and

spread to your brain"

• "It is limited to brain tissue"

rationale: benign

A nurse is reviewing the health record of a client who has a malignant tumor and notes the client has a positive Romberg's sign. Which of the following actions should the nurse take to assess for this sign?

• stroke the lateral aspect of the sole of the foot
• Ask client to blink eyes
• Observe facial drooping
• Have client stand erect with eyes closed
• Have client stand erect with eyes closed

rationale: Romberg tests for balance

A nurse is beginning a physical assessment of a client who was recently diagnosed with MS. Which of the following findings should the nurse expect? SATA

• Area of paresthesia
• Involuntary eye movements
• Alopecia
• Increased Salivation
• Ataxia
• Area of paresthesia
• Involuntary eye movements
• Ataxia

Paresthesia is a finding in a client with MS.Nystagmus is a finding in a client with MS.Ataxia occurs in the client with MS as muscle weakness develops and there is loss of coordination A nurse is caring for a client who has Myasthenia Gravis and has developed drooping eyelids. Which of the following actions should the nurse take? SATA

• Apply lubricating eye drops
• Encourage use of sunglasses
• Support head with pillows
• Tape eyes closed at night
• Provide periods of rest during the day
• Apply lubricating eye drops
• Tape eyes closed at night

A nurse is caring for a client who has multiple sclerosis.Which of the following findings should the nurse expect?

• Fluctuations in blood pressure
• Loss of cognitive function
• Ineffective cough
• Drooping eyelids
• Loss of cognitive function

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?

• "This medication will help you with your tremors."
• "This medication will help you with your bladder

function."

• "This medication may cause your skin to bruise easily."
• "This medication may cause your skin to appear yellow

in color."

• "This medication may cause your skin to appear yellow in color."

Med to help with spasms. Adverse effect of this medication is jaundice. Can indicate impaired liver function.A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?

• "This medication will help you with your tremors."
• "This medication will help you with your bladder

function."

• "This medication may cause your skin to bruise easily."
• "This medication may cause you to experience

weakness."

• "This medication may cause you to experience weakness."

A nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time?

• Keep neck stabilized
• Insert nasogastric tube
• Monitor pulse and blood pressure frequently
• Establish IV access and start fluid replacement
• Keep neck stabilized

The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist.A nurse is caring for a client who has just been admitted following a surgical evacuation of a subdural hematoma.Which of the following is the priority assessment?

• Glasgow Coma Scale
• Cranial Nerve Function
• Oxygen saturation
• Pupillary response
• Oxygen saturationABC's.

Brain tissue can only survive for 3 minutes before permanent damage occurs.

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

• Suction the ET tube frequently
• Decrease the noise level in the clients room
• Elevate the client's head on two pillows
• Administer a stool softener
• Keep the client well hydrated

B, D.Decrease the noise level can decrease ICP level.Stool softener decreases the need to bear down during BM's, which can increase ICP.Critical care unit is completing an admission assessment of a client who has a GSW to the head. Which of the following assessment findings are inidicative of increased ICP? Select all that apply.

• Headache
• Dilated Pupils
• Tachycardia
• Decorticate posturing
• Hypotension

A, B, D.

Headache, Dilated pupils, and decorticate/decerebrate posturing are all findings associated with increased ICP.A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor?

• Hyperglycemia
• Hyponatremia
• Hypervolemia
• Oliguria
• Hyponatremia

Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.A nurse is caring for a client who has experienced a right- hemispheric stroke. Which of the following findings are expected? Select all that apply.

• Impulse control difficulty
• Left hemiplegia
• Loss of depth perception
• Aphasia
• Lack of situational awareness

A, B, C, E.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

• Teach the client to scan to the right to see objects on

the right side of her body

• Place the bedside table on the right side of the bed
• Orient the client to the food on her plate using the

clock method

• Place the wheelchair on the clients left side
• Place the bedside table on the right side of the bed

The client is unable to visualize to the left midline of her body. If its on the right, she will be able to see it at all times.