ATI QUESTIONS TO REVIEW BEFORE EXIT & NCLEX

ATI QUESTIONS TO REVIEW BEFORE EXIT & NCLEX:

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HESI C

125 term K_C A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate?A.) Apply cold compresses to the affected extremity B.) Apply warm compresses to the affected extremity C.) Keep the affected extremity above the level of the heart D.) Keep the affected extremity below the level of the heart ANSWER--->D.) Keep the affected extremity below the level of the heart

RATIONALE: The nurse should NEVER apply direct heat to the limb. Sensitivity is

decreased in the affected limb & burns may result A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority?A.) Securing the tube and drainage bulb to the pt B.) Keeping the drainage bulb depressed to manual suction C.) "Milking" the tubing before emptying the drain D.) Cleansing the insertion site of the tube w/betadine ANSWER-->B.) Keeping the drainage bulb depressed to manual suction

RATIONALE: Securing the tubing helps to keep tension from being placed on the

tubing & bulb. While this is helpful, maintaining the bulb to suction is the highest priority nursing intervention A client is scheduled for surgery. Which of the following findings should the nurse report to the provider prior to surgery?A.) Serum potassium of 3.8 mEq/L B.) A missing identification band C.) Increased anxiety level D.) A decrease in BP ANSWER-->D.) A decrease in BP

RATIONALE: If a missing ID band is noted the nurse can recreate the band prior

to proceeding to the operating room. The ID band is a method of properly identifying a pt & necessary for care

A client is undergoing cystoscopy. Which of the following interventions should the nurse include in the client's plan of care?A.) Provide education on home urinary catheter care B.) Monitor for infection for 48-72 hours following procedure C.) Increase oral fluid intake to flush contrast dye from system

• Educate pt on the need for anticoagulant therapy

ANSWER--->B) Monitor for infection for 48-72 hours following procedure

RATIONALE: Cystoscopy does not require administration of contrast dye

A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately?A.) Chest tube & tubing become disconnected during pt transfer

• Pt complains of left-sided chest pain of 7 on pain scale

when performing incentive spirometry

• Chest tube drainage measures 80 mLs/hr of red blood
• Diminished breath sounds auscultated in left lower

lobe ANSWER-->C) Chest tube drainage measures 80mL/hr of red blood RATIONALE: If the tubing separates the RN will ask the pt to exhale as much air as they can to remove air from the pleural space & the nurse would cleanse the tips & reconnect the tubing A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis. Which of the following should be included?A.) Increase intake of dietary calcium

• Walking for one to two hours daily is recommended.
• Eliminate safety hazards in the home
• Long-term estrogen replacement therapy will be

required.ANSWER-->C.) Eliminate safety hazards in the home

RATIONALE: Intake of calcium alone is not a treatment for osteoporosis, but

calcium is an important part of a prevention program to promote bone health.Most people do not get enough calcium in their diet, and therefore calcium supplements are needed.A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement?

• Aspirate to collect gastric content.
• Test pH of gastric contents
• Ask the client to talk.
• Inject air into tube and listen over abdomen.

ANSWER-->D.) Inject air into tube and listen over abdomen RATIONALE: Other than X-ray, aspiration of gastric contents with pH testing is the most reliable method to determine correct NG tube placement. A pH of 4 or less is expected.A nurse is caring for a client with heart failure. Which of the following interventions should the nurse take if the client is experiencing dyspnea?

• Place client in high Fowler's position.
• Place client in the reverse trendelenberg position
• Perform coughing and deep breathing exercises every
• hours.
• Obtain serial ABGs every 8 hours.

ANSWER-->A) Place pt in high fowler's position

RATIONALE: Placing the client in reverse trendelenberg would not promote lung

expansion and improve oxygenation as well as high Fowler's position.

A nurse is providing education to a client with coronary artery disease. Which of the following cholesterol values should the nurse identify as a goal for this client?

• HDL-C level 60 mg/dL
• HDL-C level 20 mg/dL
• LDL-C level 98 mg/dL
• LDL-C level 120 mg/dL

ANSWER-->A) HDL-C level 60 mg/dL RATIONALE: While a value of <130>

• Increase in pulse rate
• A decrease in temperature
• A decrease in blood pressure
• Increased oxygen saturation

ANSWER-->C) A decrease in BP RATIONALE:An increase in a client's pulse rate is a finding that needs additional data collection because it may be indicative of an autonomic response to pain, anxiety, and other A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completing an abdominal assessment?

• Hyperactive bowel sounds.
• Hypoactive bowel sounds.
• Normal bowel sounds.
• Absent bowel sounds.

ANSWER-->A) Hyperactive bowel sounds

RATIONALE: Hypoactive bowel sounds may be found in later stages of

obstruction, but hyperactive bowel sounds are typical in early stages of obstruction.A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately?

• Hyperactive deep tendon reflexes
• Increase in white blood cell count from 6,000 mm3 to

8,000 mm3

• Increase in temperature from 99.5 F to 100.5 F
• Increased number of stools

ANSWER-->C) increase in temp from 99.5 to 100.5 F

RATIONALE: Hyperactive deep tendon reflexes are a common manifestation of

Grave's disease.A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis?

• Intake and output
• Pulse oximetry
• Lung sounds
• Daily weight

ANSWER-->B) pulse oximetry RATIONALE: Lung sounds should be monitored in the client at risk for atelectasis but this is not the best method to monitor for the manifestations of atelectasis.

A nurse is caring for a client post aortofemoral bypass surgery. Which of the following interventions would be contraindicated?

• Monitoring client for changes in blood pressure.
• Encouraging client to sit in high Fowler's position.
• Maintaining NPO status until first postoperative day.
• Coughing and deep breathing every 1 to 2 hours.

ANSWER-->B) Encouraging pt to sit in high-fowlers position

RATIONALE: Coughing and deep breathing should be encouraged to promote

gas exchange and prevent atelectasis.A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching?

• Tub baths the night following the procedure are

acceptable.

• Notify provider if bruising is noted at the site.
• Remove dressing the evening of the procedure.
• Limit activity for several days after the procedure.

ANSWER-->D) limit activity for several days after the procedure RATIONALE: Mild bruising at the insertion site is not unusual and will resolve after several days.A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs?

• The client begins to breathe harder
• The client experiences an increase in heart rate.
• An ST segment depression or T wave inversion on the

EKG.

• QRS complexes begin to occur more frequently.

ANSWER--->C) An ST segment depression or T wave insertion on the EKG

RATIONALE: QRS complexes are a normal part of the cardiac cycle and an

increase in QRS complexes represents an increase in heart rate - a normal finding with exercise.A client experiencing intermittent chest pain has been admitted to the hospital. Which of the following laboratory values should the nurse report to the health care provider immediately?

• Total myoglobin 60 mcg/L
• Cardiac troponin T 1.2 ng/mL
• C-reactive protein (CRP) 0.2 mg/dL
• Creatine kinase (CK) 90 units/

ANSWER-->B) Cardiac troponin T 1.2 ng/mL

RATIONALE: Normal creatine kinase for females is 30-135 units/L and 55-170

units/L for males.